Citation Nr: 18158704 Decision Date: 12/17/18 Archive Date: 12/17/18 DOCKET NO. 15-27 861 DATE: December 17, 2018 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to the service-connected posttraumatic stress disorder (PTSD) disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1988 to December 1991. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before a Decision Review Officer in July 2015; a transcript of that hearing is associated with the claims file. The Veteran contends that he is entitled to service connection for OSA as secondary to his service-connected PTSD disability. As an initial matter, the Board observes that the record, to specifically include a September 2013 VA sleep apnea Disability Benefits Questionnaire (DBQ), reflects a current diagnosis of OSA. The Veteran is also currently in receipt of a 70 percent rating for his service-connected PTSD disability. Therefore, the Veteran’s claim turns upon whether his currently diagnosed OSA is secondary to his service-connected PTSD disability. In this regard, the September 2013 VA examiner opined that the Veteran’s OSA was not proximately due to, or the result of, his service-connected PTSD disability. In support of this opinion, the examiner stated that the Veteran’s “sleep apnea more likely aggravates the PTSD symptoms; veteran has insomnia and lack of restful sleep due to his PTSD.” The Board finds the September 2013 medical opinion to be inadequate as it failed to include a complete rationale for the conclusions reached. In this regard, the examiner appears to have opined that the Veteran’s sleep impairment (which includes symptoms of insomnia and lack of restful sleep) are solely due to his PTSD symptoms. The examiner did not explain why, for instance, the Veteran’s lack of restful sleep was not also due to his OSA. Further, the examiner indicated that the Veteran’s insomnia and lack of restful sleep were aggravated by the Veteran’s OSA. A reason was not provided, however, as to why the Veteran’s OSA symptoms (which could reasonably include lack of restful sleep) were not aggravated by his PTSD disability. The Veteran also submitted opinions from various sources, including E. G. (a physician’s assistant, opinion dated in March 2013), E. R. (a certified respiratory therapist, opinion dated in March 2013), M. W. (a licensed social worker, opinion dated in October 2013), and an August 2014 DBQ completed by C. O. (a certified physician’s assistant). All of the medical opinions provided by the abovementioned medical professionals indicated that the Veteran’s OSA was aggravated (or possibly) aggravated by his service-connected PTSD disability. Unfortunately, none of these medical professionals provided a rationale to support their respective opinions. See Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record). As such, these opinions lack probative value. The Board has also reviewed the internet articles submitted by the Veteran in July 2015. Medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998). However, internet articles tend to be general in nature and do not relate to the specific facts in a given claim. The internet articles submitted by the Veteran provide general information without a specific connection to the details of the cause of his OSA. The articles are not combined with an opinion of a medical professional. As such, without a corresponding medical opinion specific to the Veteran’s case, these articles are insufficient to grant the claim at this time. For these reasons, the Board finds that a new examination and medical opinion, which takes into consideration all the evidence of record, is warranted to assist in determining whether the Veteran’s OSA is aggravated by his service-connected PTSD disability. The matter is REMANDED for the following actions: 1. Obtain any outstanding VA treatment records since June 2017 and associate them with the claims file. 2. Then, schedule the Veteran for a VA sleep apnea examination. The examiner must review the claims file and should note that review in the report. After performing an examination, the examiner should address the following: (a.) Differentiate (if possible) between which sleep impairment symptoms are associated with the Veteran’s diagnosed obstructive sleep apnea versus his psychiatric disability. (b.) For symptoms that are found to be associated with his sleep apnea, the examiner should opine as to whether they are at least as likely as not (50 percent or greater probability) aggravated (permanently increased in severity beyond the natural progress of the disorder) by the service-connected PTSD disability. **In making this determination, the examiner is asked to review the medical articles submitted by the Veteran (entry dated 7/8/15) and the statements provided by E. G. (a physician’s assistant), E. R. (a certified respiratory therapist), M. G. (a licensed social worker), and the August 2014 DBQ completed by C. O. (a certified physician’s assistant). (c.) All opinions should be accompanied by a rationale consistent with the evidence of record. 3. Then, readjudicate the claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Casadei, Counsel