Citation Nr: 20006908 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 17-58 163 DATE: January 28, 2020 REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from April 1981 to April 1984. This appeal comes to the Board of Veterans’ Appeals (Board) from a July 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. At the hearing, the Veteran’s representative indicated they would be submitting a trial brief following the hearing; this was received in October 2019. Additionally, the record was held open for 60 days following the hearing to allow for the submission of additional evidence. During this period, only the trial brief with its enclosed evidence was received. 1. Entitlement to service connection for sleep apnea is remanded. At the August 2019 Board hearing, the Veteran offered multiple theories of entitlement in support of his claim for sleep apnea. First, he asserted his obstructive sleep apnea might be directly related to his service because he believed his symptoms had their onset within one year of active reserve service in 1987. He also indicated that during service he recalled having poor sleep habits, such as snoring heavily or not being able to sleep. Second, he asserted his obstructive sleep apnea was aggravated beyond its natural progression due to his service-connected posttraumatic stress disorder (PTSD). In support of the second contention, the Veteran’s representative submitted medical articles concerning the relationship between sleep apnea and psychiatric disabilities. He also submitted a private Disability Benefits Questionnaire (DBQ), dated July 2019, in which the Veteran’s physician noted the Veteran was unable to wear a CPAP mask consistently because of his PTSD. See October 2019 trial brief enclosures. The record shows the Veteran has a sleep apnea diagnosis. He has not been provided a VA examination to assess the nature and etiology of the disability. In light of the foregoing contentions and evidence submissions, the Board finds a VA examination for a medical opinion is necessary. 2. Entitlement to service connection for bilateral hearing loss is remanded. The record establishes that the Veteran has a diagnosis of bilateral sensorineural hearing loss pursuant to 38 C.F.R. § 3.385. At the June 2017 VA audiological evaluation, he described being exposed to loud noises in service as a result of his military occupational specialty (MOS). After examining the Veteran and reviewing his claims file, the examiner opined the Veteran’s bilateral hearing loss was not at least as likely as not caused by or a result of an event in military service. She explained that records reviewed revealed the Veteran to have normal hearing sensitivity at both service entrance and separation examinations with no significant threshold shifts. The examiner stated that an audiogram was the objective standard for noise injury, and because the Veteran’s hearing was normal at separation, there was no evidence that his military noise exposure had caused a permanent noise injury affecting his hearing sensitivity. Additionally, the examiner stated that according to the American College of Occupational Medicine Noise and Hearing Conservation Committee, "a noise induced hearing loss will not progress once it is stopped." Therefore, it was her opinion that the Veteran’s current hearing loss was less likely than not related to military nose exposure/acoustic trauma. At the August 2019 Board hearing, when asked when his hearing loss began after service, the Veteran stated he first experienced hearing loss symptoms while in service but did not report it to anyone because he was young and thought it was normal. He also testified he was afraid to report the symptoms. The Veteran’s representative suggested that a subsequent treatment provider in July 2019 had stated that the Veteran’s hearing was gradually getting worse and was related to his time in service. However, a review of the July 2019 audiology consult note submitted with the representative’s trial brief shows that although the Veteran’s complaint of worsened hearing was documented along with his reports of military noise exposure, no opinion as to the etiology of the Veteran’s bilateral hearing loss was offered. Notwithstanding that, also in the trial brief, the Veteran’s representative cited to and provided copies of two medical articles indicating that repeated exposure to loud noises can cause delayed, even gradual, hearing damage. As this additional evidence conflicts with the June 2017 VA examiner’s opinion, the Board finds an addendum medical opinion is necessary for consideration of the newly submitted evidence and clarification as to whether the Veteran’s current bilateral hearing loss is related to his in-service noise exposure. The matters are REMANDED for the following action: 1. Arrange for a VA examination and a medical opinion from an appropriate VA clinician to determine whether the Veteran's obstructive sleep apnea is (1) at least as likely as related to his service, (2) at least as likely as not caused by his service-connected PTSD, or (3) at least likely as not aggravated beyond its natural progression by his service-connected PTSD. In answering the above questions, the examiner must review the claims file (including a copy of this remand) and address the Veteran’s contention that his symptoms (to include snoring and not being able to sleep) began in service. The examiner should also address the medical articles submitted concerning the relationship between sleep apnea and psychiatric disabilities, as well as the private DBQ dated July 2019, in which the Veteran’s physician noted the Veteran was unable to wear a CPAP mask consistently because of his PTSD. A rationale for all opinions expressed should be provided. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. 3. Forward the Veteran’s claims file (including a copy of this remand) to an appropriate clinician for review and an addendum medical opinion as to whether the Veteran's bilateral hearing loss is at least as likely as not related to his service. In providing the requested opinion, the examiner should consider and discuss the medical articles submitted by the Veteran’s representative in October 2019. The examiner must also address the Veteran’s contention that his symptoms (hearing loss) began in service. A rationale for all opinions expressed should be provided. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. Rationales for all requested opinions shall be provided. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the clinician shall 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 particular question. If the examiner determines that a physical examination of the Veteran is necessary to provide the requested opinions such should be arranged. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Kilbride, Law Clerk 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.