Citation Nr: 20003572 Decision Date: 01/15/20 Archive Date: 01/15/20 DOCKET NO. 19-18 867 DATE: January 15, 2020 REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1982 to July 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2018 rating decision by the Agency of Original Jurisdiction (AOJ), which denied entitlement to service connection for obstructive sleep apnea. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran has been diagnosed with obstructive sleep apnea (OSA) and he contends the disability was caused or aggravated by his service-connected PTSD. See November 2019 Appellate Brief. Specifically, the Veteran has asserted he is not sleeping because of his PTSD. The Veteran reported that because of his OSA, he obtains approximately four hours of sleep per day and his overall health has been adversely affected. See June 2019 VA Form 9. The August 2018 VA examiner opined that the Veteran’s OSA was less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. See August 2018 VA examination report at 3-4. The VA examiner reasoned that there is no currently available authoritative data which indicates a cause and effect relationship between PTSD and OSA. Id at 4. However, the VA examiner did not address whether the Veteran’s PTSD aggravated the Veteran’s OSA. The United States Court of Appeals for Veterans Claims (Court) held that the phrases “caused by” and “related to” do not address the aggravation aspect of secondary service connection. See Allen v. Brown, 7 Vet. App. 439. Moreover, the Court has held that when an examiner determines whether service connection is warranted on a secondary basis, he or she must address both direct causation as well as aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013) Here, because the August 2018 VA examination report did not adequately address whether the Veteran’s OSA was aggravated by his service connection PTSD, the VA examination report is inadequate. The Board notes that in support of the secondary aspect of the claim, the Veteran cited a peer-reviewed study titled “Obstructive Sleep Apnea and Posttraumatic Stress Disorder among Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Veterans.” See November 2019 Appellate Brief at 3. The study concluded that OEF/OIF/OND veterans with PTSD screen as “high risk” for OSA at much higher rates and such veterans may not show all classic predictors of OSA (snoring, fatigue, high blood pressure/body mass index, etc.). Id. Accordingly, on remand, the reviewing clinician is asked to review the article cited above, to include any other relevant literature, and opine on whether it is at least as likely as not that the Veteran’s service-connected PTSD caused or aggravated his OSA. The matters are REMANDED for the following action: 1. Obtain any outstanding updated VA and/or private treatment records relevant to treatment the Veteran received for his OSA. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified, and the record clearly documented. 2. Thereafter, obtain an opinion from an appropriately qualified clinician regarding the nature and the etiology of the Veteran’s claimed OSA. The record, including a copy of this remand, must be made available and reviewed by the clinician. It is up to the discretion of the reviewing clinician as to whether a new examination is necessary to provide an adequate opinion. After the file review and examination of the Veteran, if deemed necessary, the reviewing clinician should render the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s OSA had its onset in service or is otherwise related to an in-service event, injury or disease? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s OSA is proximately due to the Veteran’s PTSD? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s OSA was aggravated by the Veteran’s PTSD? The reviewing clinician should review and discuss the peer-reviewed article cited in the Veteran’s representative’s November 2019 Appellate Brief titled: “Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans.” The reviewing clinician is not to improperly discount the Veteran’s lay statements or mistakenly rely on an absence of medical evidence of record to support his/her conclusions. 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 reviewing clinician must provide a complete explanation for why an opinion cannot be rendered. In so doing, the reviewing 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 question. 3. After the above has been completed to the extent possible, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Glen J. Capers, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.