Citation Nr: 20005753 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 09-10 723 DATE: January 23, 2020 REMANDED Entitlement to service connection for obstructive sleep apnea, as secondary to posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1962 to April 1966. This matter was last before the Board in April 2018, whereupon it was remanded for further development of the record. Following the issuance of a November 2019 supplemental statement of the case that continued the denial of service connection, the case was returned to the Board for its adjudication. Pursuant to the Board’s April 2018 remand directives, the Regional Office was directed to obtain an addendum opinion from a certified physician’s assistant or physician responsive to the query of whether it was at least as likely as not that the Veteran’s service-connected PTSD or any medication prescribed for the disability caused the Veteran to gain weight. If so, the examiner was then instructed to offer two additional opinions: 1) whether it was at least as likely as not that the weight gain was a substantial factor in causing his obstructive sleep apnea, and 2) whether it was at least as likely as not that the obstructive sleep apnea would not have occurred but for the PTSD-related weight gain. In an October 2019 opinion, a VA physician’s assistant found that the Veteran’s PTSD “cannot be considered a definite etiology of obstructive sleep apnea,” and later reiterated that the Veteran’s obesity “cannot be attributed to the service-connected PTSD.” This opinion is unfortunately insufficient for a variety of reasons. To begin, the examiner did not utilize the correct standard of evaluation as they did not express their opinion in the form of a probability. To be precise, the standard is not whether a mental health condition is a “definite” etiology of obstructive sleep apnea, but instead whether there is at least a 50 percent probability or greater that the mental health condition resulted in weight gain. For this reason alone, remand is necessary. However, the Board notes additional deficiencies that must also be corrected. Namely, the October 2019 examiner did not discuss the potential impact on his weight of the Veteran’s prescribed medication for the treatment of his PTSD as instructed by the Board. Furthermore, the October 2019 examiner apparently did not discuss medical research submitted by the Veteran and included in the claims file that suggests that there may be a connection between mental health disability and weight gain. On remand, the claims file must be reevaluated, and a new opinion or opinions must be secured that are fully responsive to the Board’s prior April 2018 remand instructions, which are copied in large part below. Stegall v. West, 11 Vet. App. 268 (1998). The matter is REMANDED for the following action: Return the claims file to the physician’s assistant who issued the October 2019 addendum opinion, or to an equally qualified medical professional if that individual is not available, for the purpose of eliciting a further addendum opinion to the previous July 2017 and October 2019 opinions as to the likely etiology of the Veteran’s obstructive sleep apnea. The claims file must be reviewed by the examiner. The chosen examiner is asked to indicate whether he or she concurs with the findings set forth by the July 2017 and October 2019 examiners and to specifically respond to the following: (a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s service-connected PTSD OR any medication prescribed for the disability caused OR contributed to the Veteran’s weight gain and obesity? (b) If so, is it at least as likely as not that the Veteran’s obesity/weight gain was a contributing factor in causing his obstructive sleep apnea? (c) In addressing (b), the examiner must consider whether it is at least as likely as not that the Veteran’s obstructive sleep apnea would not have occurred but for the obesity/weight gain cause by his service-connected PTSD or medication prescribed for the disability. In setting forth these opinions, the examiner is asked to consider and comment upon as necessary medical literature submitted by the Veteran in support of his contention that there is a causal link between his PTSD and his history of weight gain and eventual obesity. A complete rationale is required for any opinion provided. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, 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.