Citation Nr: 20031345 Decision Date: 05/05/20 Archive Date: 05/05/20 DOCKET NO. 14-26 669 DATE: May 5, 2020 REMANDED The issue of entitlement to service connection for obstructive sleep apnea (OSA), to include whether OSA was worsened by service-connected PTSD is remanded. REASONS FOR REMAND The Veteran had active service from January 1983 to August 1991. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR RO ADJUDICATOR: The Veteran contends his OSA disability was incurred in service, or, alternatively, that his OSA disability is aggravated by his service-connected posttraumatic stress disorder (PTSD) disability. The VA medical opinions on file to do not address the Veteran’s contention for aggravation (WORSENING) by a service-connected disability. An addendum opinion is needed to fully and fairly evaluate the Veteran’s claim. 2. Arrange for an appropriate examiner (if feasible other than the October 2019 VA examiner) to provide an addendum medical opinion to assist in determining the relationship between the Veteran’s current OSA diagnosis and his service and service-connected PTSD disability. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinions: a) Did the Veteran demonstrate the onset of OSA during service? b) Is the Veteran’s current OSA diagnosis proximately due to his service-connected PTSD? c) Is the Veteran’s current OSA diagnosis aggravated (e.g. worsened, and if so, to what degree) by the Veteran’s PTSD? d) If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must review the entire record in conjunction with rendering the requested opinions. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner’s attention is drawn to the following: * December 2009 to June 2010 VA treatment records indicate that during mental health sessions the Veteran reported increase PTSD symptomatology since using the CPAP machine the previous summer. See “CAPRI,” received May 27, 2018, page 168-9 of 296. * November 2010 VA medical examination report of initial evaluation for PTSD, when the Veteran reported sleeping with the CPAP mask reminded him of sleeping with a mask during service in Southwest Asia and that his intrusive memories, flashbacks and nightmares of combat service in Southwest Asia had increased since beginning CPAP treatment for his OSA. See “VA Examination,” received November 3, 2010. * May 2012 statement that the Veteran’s fellow service members reported to him that he snored loudly. He also stated that he experienced daytime fatigue and sleepiness, and weight gain, during service. See “VA 21-4138 Statement in Support of Claim,” received May 30, 2012. * June 2012 statement by the Veteran’s spouse that the Veteran snored loudly and frequently stopped breathing during sleep since they began cohabitation in November 1991, a few months after the Veteran’s discharge from service. See “VA 21-4138 Statement in Support of Claim,” received June 1, 2012. * November 2012 VA neurology examiner noted the Veteran’s PTSD affected the Veteran’s use of his CPAP mask because the Veteran reported increased flashbacks of wearing his “gas mask” during Southwest Asia service. See “CAPRI,” received May 27, 2018, page 548 of 715. * April 2013 VA treatment records indicate the Veteran reported intermittent intrusive thoughts that affected his sleep and that the use of CPAP mask “occasionally” worsened this PTSD symptom. See “CAPRI,” received May 27, 2018, page 539 of 715. * February 2015 VA medical examination report regarding the severity of the Veteran’s PTSD, when the Veteran reported using the CPAP mask induced intrusive memories of service. See “C&P Exam,” received February 4, 2015. * July 2015 Board hearing testimony regarding the onset of symptoms in service. See “Hearing Testimony,” received July 15, 2015. * August 2015 Informal Hearing Presentation by the Veteran’s authorized representative, noting that the Veteran reported that using his CPAP mask to treat his OSA induced memories and dreams of service. The authorized representative also noted medical studies that indicated soldiers with PTSD have significantly decreased adherence to CPAP adherence, and that veterans with PTSD have a high prevalence of sleep disorders such as insomnia and OSA. See “BVA Decision,” received October 26, 2016. * May 2016 VA medical examination report and opinion for OSA. During the examination the Veteran reported that wearing his CPAP mask aggravated his PTSD symptomatology such as nightmares, flashbacks and intrusive thoughts because the CPAP mask reminded him of wearing a protective mask while deployed in Southwest Asia. The examiner opined the Veteran’s OSA was less likely than not due to his service-connected PTSD. However, the examiner did not opine on aggravation. See “C&P Exam,” received June 6, 2016. * April 2018 VA medical examination report regarding the severity of the Veteran’s PTSD disability, when the Veteran reported continuing chronic sleep impairment. See “C&P Exam,” received April 30, 2018. * June 2018 VA sleep clinic follow-up notation, when the Veteran reported sleeping less due to increased PTSD symptoms, even with his nightly use of the CPAP mask. The Veteran was encouraged to lose weight. In September 2018 the Veteran reported poor sleep even with continued use of CPAP mask. See “CAPRI,” received August 14, 2019, pages 50, 64 of 73. * July 2019 VA treatment records indicate that during a CPAP consultation, the examiner noted the Veteran had a history of excellent adherence to the CPAP mask, and that the Veteran denied issues with the mask, machine or pressure. The examiner advised the Veteran to continue to use the mask consistently, even during naps. “See “CAPRI,” received August 14, 2019, page 13-14 of 67. * The October 2019 VA medical examination report and opinion, where the examiner opined the Veteran’s OSA was less likely than not incurred in service, to include due to exposure to hazardous materials, but rather was more likely than not due to the Veteran’s weight, noting that the link between being overweight and acquiring OSA was well established. See “C&P Exam,” received October 11, 2019. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. The examiner should schedule a new examination only if necessary to provide an adequate opinion. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED, AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THE EXAMINATION/OPINION SUFFICIENT. 3. Following the review and any additional development deemed necessary, readjudicate the claim. Should the claim not be granted in its entirety, issue an appropriate supplemental statement of the case (SSOC) and forward the claim to the Board for adjudication. (Continued on the next page)   The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Anwar, Attorney-Advisor 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.