Citation Nr: 20021890 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 16-13 327 DATE: March 27, 2020 REMANDED Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The appellant is a Veteran who served on period of active duty for training (ACDUTRA) from July 1992 to November 1992, and on active duty from February 2003 to May 2003, and from August 2006 to November 2007 (with service in Iraq from September 2006 to January 2007). This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision. In December 2015, November 2018, and July 2019 the matter was remanded for development Service connection for sleep apnea is remanded. The Board acknowledges that this matter has been remanded three times before (and regrets the delay inherent in yet another remand). However, the Board finds that additional development in this matter is necessary. The Board’s July 2019 remand was for an adequate medical opinion addressing whether the Veteran’s sleep apnea was aggravated by his service-connected PTSD. The Board’s review of the August 2019 addendum medical opinion received in response found deficiencies in the opinion that render it inadequate for rating purposes. Specifically, the provider did not include rationale for the opinion that the sleep apnea was not aggravated by the PTSD. The examiner stated that symptoms associated with PTSD (difficulty falling asleep, light sleeping, easily startled, easily woken, intrusive dreams) were not symptoms of sleep apnea and further stated that they did not aggravate or worsen sleep apnea. However, the examiner did not explain why they do not impact on the impairment due to sleep apnea. Accordingly, development for an addendum medical opinion that includes adequate rationale addressing the aggravation aspect of the secondary service connection theory of entitlement is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following: Arrange for the Veteran’s record to be forwarded to an appropriate clinician (other than the provider of the March 2019 and August 2019 medical opinions) for review and an advisory medical opinion regarding the likely etiology of his sleep apnea. The consulting provider should respond to the following: (a.) Is it at least as likely as not (a 50% or greater probability) that the Veteran’s sleep apnea was (i) caused or (ii) aggravated by his service-connected PTSD? [The rationale for the opinion must specifically discuss the concept of aggravation (explain why PTSD would not/did not aggravate the sleep apnea, to include by amplifying the impact of sleep apnea manifestations).] (b.) If the Veteran’s service-connected PTSD sleep apnea is determined to have neither caused, nor aggravated his sleep apnea, identify the etiology for the sleep apnea considered to be more likely and explain why that is so. The examiner must include rationale with all opinions, citing to supporting clinical data and medical principles/literature as deemed appropriate. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Staskowski, 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.