Citation Nr: 18153584 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 15-15 961 DATE: November 28, 2018 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Navy from July 1980 to July 1984, and from August 1988 to September 2006. On his May 2015 substantive appeal, the Veteran requested a Board hearing at his local VA office. In an October 2018 correspondence, the Veteran withdrew his prior hearing request. As the record does not contain any additional requests for an appeals hearing, the Board deems the Veteran’s request for a hearing to be withdrawn. See 38 C.F.R. § 20.702(e) (2018). Entitlement to service connection for obstructive sleep apnea is remanded. Although the further delay entailed by remand is regrettable, current adjudication of the Veteran’s claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2018). The Veteran contends that his OSA is related to active service. Review of service treatment records shows that Veteran was diagnosed with orbital inflammatory syndrome in August 1993. The prescribed treatment included long-term use of steroids, including cyclosporine and prednisone. Service treatment records from February 2002 and October 2002 indicate that Veteran was counseled about the long-term effects of steroid use, including excessive weight gain. A primary care note, dated August 2006, acknowledged that a July 2006 sleep study, found no significant sleep apnea. However, the study revealed moderate decreased sleep with a sleep efficiency of 82 percent. It was suggested that the decreased sleep efficiency could be a side effect of his prescribed medications, alcohol use, or environmental issues and that further exploration was warranted. Following a May 2012 sleep study at a VA medical center, the Veteran was diagnosed with moderate OSA. In December 2016, the Veteran underwent a VA examination. During the clinical evaluation, his medical history was reviewed. It was noted that a diagnosis of OSA was made following a May 2012 sleep study. By comparison, the examiner noted that the Veteran had 6 apneas and 11 hypopneas during his June 2006 sleep study and did not warrant a diagnosis of OSA, as such a diagnosis required an apnea-hypopnea index (AHI) greater than five events per hour. The examiner opined that because the Veteran’s OSA was not diagnosed until 2012, “it is more likely than not (less than 50 percent probability)” that the condition was incurred in or otherwise caused by his military service. The examiner also noted that the strongest risk factor for the development of OSA is obesity. In a subsequent December 2016 addendum, a co-signer of the original opinion clarified that the findings should read “it is less likely than not” that the Veteran’s sleep apnea was caused by or otherwise related to active service. In July 2018, the Veteran submitted a June 2018 disability benefits questionnaire and opinion from a private clinician, G. U. The private clinician noted that the Veteran had gained 83lbs since his induction into active service and stated that the Veteran’s service-connected depressive disorder, right knee disability, as well as his various medications could have caused or aggravated his weight and sleep disturbances. On review of the record, the Board finds an addendum opinion is warranted. Specifically, the December 2016 focused on obesity as a causal risk factor for the development of sleep apnea, but did not address the evidence indicating that the Veteran’s in-service use of oral steroids and / or service-connected disabilities may have caused his weight gain. Accordingly, a remand for an addendum opinion is required. The matter is REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. After the above is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's sleep apnea. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s OSA had its onset during service or is otherwise related to service, to include the Veteran’s in-service use of oral steroids. In so opining, the clinician should also address the lay statements from the Veteran and his wife noting that the Veteran experienced sleep problems during and since active service. (b.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s OSA was caused by his service-connected depressive disorder, right knee disability, right eye disability, or any medication taken for those disabilities? (c.) If not caused by the Veteran’s service-connected depressive disorder, right knee disability, right eye disability, or any medication taken for those disabilities, is it at least as likely as not that the Veteran's OSA is worsened beyond natural progression (aggravated) by his service-connected depressive disorder, right knee disability, right eye disability, or any medication taken for those disabilities? If the clinician finds that the Veteran's OSA was aggravated by his service-connected depressive disorder, right knee disability, right eye disability, or any medication taken for those disabilities, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the OSA. In so opining, the clinician should address the June 2018 DBQ and opinion from G. U. A complete rationale should be provided for all opinions and conclusions expressed. If the examiner is unable to offer an opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). J. A. Anderson Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Whitaker, Associate Counsel