Citation Nr: 20003776 Decision Date: 01/15/20 Archive Date: 01/15/20 DOCKET NO. 16-45 611 DATE: January 15, 2020 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a respiratory disorder(s), other than allergic rhinitis and sleep apnea, is remanded. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had service from January 1972 to November 2013, with various periods of active duty, reserve duty, active duty for training (ACDUTRA), and inactive duty for training (INACDUTRA). The record currently verifies active duty service from January 1972 to January 1983, from April 1996 to January 1998, from January 2008 to October 2008, from August 2011 to January 2012 and from March 2012 to November 2012. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), wherein the RO denied entitlement to service connection for hypertension, OSA and bronchitis. The Veteran’s service treatment records (STRs) and post-service treatment records contain notations of acute bronchitis, chronic bronchitis, viral syndrome, breathing issues, upper respiratory infections, mild restrictive lung disease and chronic or persistent cough. To ensure that all potential respiratory disorders are contemplated, the Board has recharacterized the issue on appeal. See Clemmons v. Shinseki, 23 Vet. App. 1 (2009). In October 2019, the Veteran testified at a Board video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. [Tr.] REASONS FOR REMAND 1. Entitlement to service connection for OSA. Although the Board regrets the delay, a remand is required for a supplemental opinion as to the etiology of the Veteran’s OSA. The Veteran contends that he has OSA as a result of his active military service. A review of the record shows that the Veteran reported exposure to smoke from burning trash or feces while stationed in Kyrgyzstan on a Post-Deployment Health Assessment completed in August 2008. In a December 2011 Post-Deployment Health Re-Assessment, the Veteran again reported exposure to smoke from burning trash or feces, as well as exposure to sand/dust and smoke from oil fire. In a September 2016 lay statement, the Veteran’s wife reported that she had at that time been married to the Veteran for 22 years, that he has always snored, that his snoring has gotten worse over the years and that he wakes up gasping for air at times. She also reported that his snoring intensified after particular deployments, including to Afghanistan, Korea, Oman and Kyrgyzstan. Also in a September 2016 lay statement, the Veteran’s daughter reported that when her father came home from a deployment, he would fall asleep on the couch and would snore and then just stop breathing. The Board cannot make a fully-informed decision on the issue of service connection for OSA because no VA examiner has opined whether the Veteran’s OSA is caused by or related to his reports of in-service exposure to burning trash, feces and oil. As a result, remand for a supplemental VA examination is necessary. Lastly, the Veteran contends he suffered OSA symptoms during active duty. See June 2016 NOD. At the Board hearing, the Veteran testified that he had an additional active duty period in September 2013 and was diagnosed with OSA in October 2013. Tr. 5. The Veteran, through his representative, submitted a copy of orders dated September 4, 2013 for active duty for operational support in Ullan Bataar, Mongolia with itinerary dates of August 31, 2013 to September 7, 2013. There is, however, no other evidence of this active duty service period in the record. On remand, the Agency of Original Jurisdiction (AOJ) should attempt to verify any period of active duty for this Veteran from November 2012 through November 2013, obtaining a points statement or pay records if determined to be necessary. 2. Entitlement to service connection for hypertension. The Veteran contends that his hypertension began during active service. During the Board hearing, the Veteran also contended that his hypertension could be a result of his OSA. Additionally, the Veteran submitted a note dated October 14, 2019 from a private advanced nurse practitioner which stated that sleep apnea can cause hypertension, and also a letter dated October 15, 2019 from the Veteran’s private doctor which stated there is a strong relation between untreated sleep apnea and hypertension. See Medical Treatment Record – Non-Governmental Facility received by VA October 2019. The Board cannot make a fully-informed decision on the issue of service connection for hypertension because no VA examiner has opined whether the Veteran’s hypertension is caused by related to his active duty service, or whether it is caused by or related to his OSA. The Veteran was afforded a VA hypertension examination in September 2015 and a December 2013 diagnosis of hypertension was noted. The VA examiner, however, provided no opinion regarding hypertension. As a result, remand is warranted to obtain a supplemental opinion on the etiology of the Veteran’s hypertension. 3. Entitlement to service connection for a respiratory disorder(s), to include bronchitis and chronic cough. The Veteran contends that he has a respiratory disorder as a result of his active military service. A review of the record shows that the Veteran reported exposure to smoke from burning trash or feces while stationed in Kyrgyzstan on a Post-Deployment Health Assessment completed in August 2008. In connection with that same assessment, the Veteran also reported that he reported to sick call for a cough lasting more than 3 weeks. In a December 2011 Post-Deployment Health Re-Assessment, the Veteran again reported exposure to smoke from burning trash or feces, as well as exposure to sand/dust and smoke from oil fire. The Veteran reported that he went to sick call with a cough lasting more than 3 weeks and for trouble breathing. The Board cannot make a fully-informed decision on the issue of service connection for a respiratory disorder because no VA examiner has opined whether the Veteran’s respiratory disorder is caused by or related to his reports of in-service exposure to burning trash, feces and oil. The Board acknowledges the May 2016 private treatment record wherein Dr. B.B. noted there has been a cough identified in soldiers exposed to fires in Afghanistan, and that it is possible that the Veteran’s cough is related to prior smoke exposure. The medical opinion is not definitive and lacks an adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A VA examination is warranted to determine the nature and etiology of the Veteran’s respiratory disorder(s). The matters are REMANDED for the following action: 1. Obtain any outstanding private and VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit copies. All records/responses received must be associated with the electronic claims file. 2. Obtain the Veteran’s complete service personnel records, to include all documents pertaining to his service in the Air Force Reserve. Verify all periods of active duty from November 2012 through November 2013. If necessary, a request should be made to the Defense Finance and Accounting Service (DFAS). Document all requests for information as well as all responses in the claims file. 3. After completion of the above directives and after any additional records are associated with the claims file, an appropriate clinician should review the entire claims file, to include a copy of this Remand, to determine the nature and etiology of the Veteran’s obstructive sleep apnea (OSA). Whether to schedule the Veteran for an additional examination shall be left to the discretion of the examiner. The examiner must address the following: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s OSA had its onset in, or is otherwise related to, active service, to include his exposure to smoke from burning trash, feces and oil during various deployments during the Gulf War. The examiner should address the Veteran’s Post Deployment Health Assessments in the STRs and the Veteran’s wife and daughter’s lay statements received by VA in September 2016. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s OSA is caused or aggravated by his hypertension. A complete rationale should be provided for all opinions both on causation and aggravation. 4. After completion of items numbered 1 and 2, and after any additional records are associated with the claims file, an appropriate clinician should review the entire claims file, to include a copy of this Remand, to determine the nature and etiology of the Veteran’s hypertension. Whether to schedule the Veteran for an additional examination shall be left to the discretion of the examiner. The examiner must address the following: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension had its onset in, or is otherwise related to, active service. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension became manifest to a compensable degree within a year of active duty service. (c) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is related to his OSA. A complete rationale should be provided for all opinions both on causation and aggravation. 5. After completion of items numbered 1 and 2, and after any additional records are associated with the claims file, please schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any respiratory disorder(s), other than allergic rhinitis and sleep apnea. The record, to include a copy of this Remand, should be made available to, and be reviewed by, the examiner. The examiner should identify all respiratory conditions. For each respiratory condition, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any respiratory disorder had onset in, or is otherwise related to, the Veteran’s active military service, to include as a result of exposure to smoke from burning trash, feces and oil. The examiner all tests deemed necessary to determine if there is a current respiratory diagnosis. The examiner should address the following: 1) the Veteran’s assertions of in-service exposure to smoke from burning feces, burning trash and oil fire during deployment to Kyrgyzstan from March 2008 to August 2008 and during deployment to Afghanistan from August 2011 to December 2011; and 2) complaints of coughing, cough lasting longer than 3 weeks, bronchitis, trouble breathing and persistent cough contained throughout the Veteran’s STRs. The examiner’s attention is particularly called to the Veteran’s Post Deployment Health Assessments in the STRs. The examiner is advised that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including injuries and symptoms, and that his reports must be considered in formulating the requested opinion. If there is a medical basis to support or doubt the Veteran’s statements, the examiner must state this with a fully reasoned explanation. A complete rationale should be provided for all opinions both on causation and aggravation. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Battaile 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.