Citation Nr: 1827079 Decision Date: 05/02/18 Archive Date: 05/14/18 DOCKET NO. 14-32 564 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, to include as a result of herbicide exposure, including as secondary to service-connected PTSD. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Polly Johnson, Associate Counsel INTRODUCTION The Veteran had active service from May 1969 to November 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran filed a notice of disagreement in October 2012. The RO furnished the Veteran a Statement of the Case in august 2014. The Veteran filed a Substantive Appeal (VA Form 9(in September 2014. In April 2017, the Veteran testified before the undersigned at a videoconference hearing. A transcript of the hearing is associated with the claims file. The Board notes that, subsequent to the issuance of the August 2014 statement of the case, additional evidence was added to the record, to include lay statements and medical treatise evidence. The Veteran waived initial agency of original jurisdiction (AOJ) consideration of this additional evidence at his April 2017 Board hearing. Inasmuch as the additional evidence pertains to the claims on appeal, and those matters are being remanded, the AOJ will have the opportunity to review this new evidence in the first instance. The issues on appeal are being REMANDED to the AOJ. VA will notify the appellant if further action is required. REMAND The Veteran contends that his obstructive sleep apnea and hypertension are caused or aggravated by his service-connected PTSD. See November 2012 Notice of Disagreement. Also, the Veteran maintains that his hypertension may be secondary to Agent Orange exposure ans/or his obstructive sleep apnea. The Veteran underwent VA examinations for his claimed conditions in October 2012. The VA examiner did not offer a nexus opinion as to obstructive sleep apnea, on either a direct or secondary basis. With regard to hypertension, the examiner opined that the Veteran's hypertension was caused by obesity, noting the Veteran's BMI range from 2004 as well as the LMD notations from 1987 and 1995 as supporting data for that conclusion. As to herbicide exposure, the examiner stated that there was no objective data to support herbicide exposure as being responsible for causing hypertension. In the August 2014 addendum opinion, which was obtained to address the theories of secondary service connection, the VA examiner opined that both hypertension and obstructive sleep apnea were less likely than not caused and/or aggravated by the Veteran's PTSD. As to hypertension, the examiner stated that during periods of heightened awareness, brief, non-clinical elevations of blood pressure may occur due to PTSD; however, there is no clinical evidence to support a causative correlation with onset of essential hypertension or any permanent worsening of the condition. The examiner stated that the Veteran's genetics and chronic obese state are the causative factors for his hypertension. As to obstructive sleep apnea, the examiner stated that the literature supports that obstructive sleep apnea is primarily caused by obesity, but other factors such as facial trauma and genetic oral-pharyngeal structures are also contributory factors. According to the VA examiner, while there is supporting data to show that PTSD does contribute to sleep disturbances (i.e., insomnia, nightmare, etc.), there is no objective evidence to support a causative correlation between PTSD and obstructive sleep apnea. In light of the foregoing, it is therefore necessary to remand this case for an addendum opinion for the purpose of obtaining further medical guidance concerning the matters of direct service connection and aggravation on a secondary basis as to sleep apnea and hypertension, as well as further clarification on the matter of Agent Orange exposure and hypertension. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify the provider(s) of any and all evaluations and/or treatment he has received for sleep apnea and hypertension and to provide authorizations for VA to obtain records of any such private treatment. Obtain for the record complete clinical records of all pertinent evaluations or treatment (records of which are not already associated with the record) from the providers identified. If any records sought are unavailable, the reason for their unavailability must be noted in the record. If a private provider does not respond to VA's request for identified records sought, the Veteran must be so notified, and reminded that ultimately it is his responsibility to ensure that private treatment records are received. 2. After instruction (1) is completed, provide the entire claims file (including a copy of this Remand) to a medical professional with appropriate expertise, and obtain from that medical professional an addendum opinion. If the designated medical professional determines that an opinion may not be offered without first examining the Veteran, then schedule the Veteran for an appropriate examination. The medical professional is requested to address the following: Obstructive Sleep Apnea: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's obstructive sleep apnea had its onset in or is otherwise related to his active military service? The examiner is to explain why that is or is not so. b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's obstructive sleep apnea has progressed at a greater rate than normally expected due to or as a result of the service-connected PTSD? The examiner is to explain why that is or is not so. Hypertension: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension had its onset in or is otherwise related to his active military service, to include his exposure to herbicide agents therein? The examiner is to explain why that is or is not so. ** The examiner must specifically address the medical literature, to include, but not limited to, the findings by VA and the Institute of Medicine that there is "limited or suggestive evidence" of a relationship between Agent Orange exposure and hypertension. See Determination Concerning Illnesses Discussed in National Academy of Sciences (NAS) Report: Veterans and Agent Orange: Update 2012, 79 Fed. Reg. 20308, 20309-10 (Apr. 11, 2014). **The fact that hypertension is not on the list of diseases presumed service connected in Veterans exposed to Agent Orange should not be the basis for a negative opinion, as the Veteran may still establish that his own hypertension was actually caused by exposure to Agent Orange. b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension has progressed at a greater rate than normally expected due to or as a result of the service-connected PTSD? The examiner is to explain why that is or is not so. The examiner must address all pertinent evidence of record, as appropriate. All findings should be reported in detail and all opinions must be accompanied by a clear rationale (explanation). 3. Then, review the record, conduct any additional development deemed necessary, and re-adjudicate the issues on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable period of time within which to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).