Citation Nr: 20032882 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 17-12 719 DATE: May 12, 2020 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1978 to May 1978. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in March 2020. A transcript of the hearing is associated with the electronic claims file. 1. Entitlement to service connection for sleep apnea, to include as secondary to hypertension is remanded. The Veteran has contended both that his sleep apnea began during active service and that it is secondary to his service-connected hypertension. In a December 2014 VA opinion, the examiner stated sleep apnea is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the result of upper airway collapse during sleep. Further, the examiner stated the Veteran's hypertension does not cause or make worse his sleep apnea. The examiner opined that it is less likely than not, that the Veteran's hypertension has any effect on his sleep apnea. There is no indication the examiner examined the Veteran or interviewed the Veteran regarding his condition and related symptoms. In an April 2015 notice of disagreement, the Veteran stated that there are three reliable clinical symptoms of sleep apnea, those are high blood pressure, snoring, and breathing stopping during sleep. The Veteran also stated approximately 50 percent of sleep apnea patients have hypertension and almost 30 percent of hypertension patients also have sleep apnea, often undiagnosed. In a November 2017 statement, the Veteran’s wife reported the Veteran has bad snoring problems and sometimes wakes up breathless. In addition, she reported the Veteran has stopped breathing when sleeping for two to 35 seconds and is often fatigued during the day. In an October 2018 private treatment note, the examiner reported the Veteran was diagnosed with sleep apnea 10 years prior. In addition, the examiner noted the Veteran snores, does not sleep well, wakes up multiple times and is sleepy during the day. The examiner reported discussing with the Veteran the potential consequences of untreated obstructive sleep apnea included cardiovascular, metabolic, mental health effect and problems with daytime functioning like driving. A January 2019 private treatment note indicated the Veteran had a new diagnosis of sleep apnea in January 2019. In addition, the examiner noted the Veteran’s hypertension and sleep apnea are major risk factors and his hypertension has significant bearing on his atrial fibrillation. At the March 2020 Board hearing, the Veteran testified that he believes his sleep apnea had its onset in service because he started having headaches in service and was diagnosed with hypertension in service. Additionally, the Veteran stated that when he was prescribed medication for high blood pressure, he was diagnosed with sleep apnea. In addition, he testified that he was hospitalized in Saginaw, Michigan a week after discharge from service for hypertension and was told that he had sleep apnea. In March 2020 supplemental remarks to the Veteran’s substantive claims, the Veteran’s attorney contended that the Veteran is entitled to service connection for his sleep apnea because his sleep apnea arose in service and is related to his service-connected hypertension. He further asserted that the Veteran’s service-connected hypertension is evidence supporting his claim that his sleep apnea began in service, since sleep apnea causes hypertension. The Veteran’s attorney included citations to studies addressing the connection between sleep apnea and hypertension. The studies submitted by the Veteran’s attorney discussing sleep apnea’s relation to hypertension and private treatment records submitted since the December 2014 VA opinion do not definitively show that the Veteran’s hypertension is related to his sleep apnea. The December 2014 VA examiner did not have an opportunity to adequately consider the Veteran’s lay statements or the submitted references to sleep articles as the references submitted were not available at the time of the opinion and the examiner did not personally interview or examine the Veteran. Thus, the Board finds a remand is necessary to procure a VA examination and opinion. The matters are REMANDED for the following action: 1. Undertake appropriate efforts to ensure all available treatment records from Saginaw, Michigan VA Medical Center and Little Rock VA Medical Center dated from May 1978 to the present are associated with the file. (The Veteran contends that he was hospitalized in Saginaw, Michigan a week after discharge from service for hypertension and was told that he had sleep apnea.) 2. Schedule the Veteran for a VA examination by a sleep specialist. The electronic claims file must be reviewed by the examiner, and a note that it was reviewed should be included in the report. The examiner should answer the following questions: a.) Is it at least as likely as not (i.e., probability of 50 percent or more) that the Veteran’s sleep apnea had its onset in service or is otherwise etiologically related to any in-service disease, injury, or event? b.) Is it at least as likely as not (i.e., probability of 50 percent or more) that the Veteran’s sleep apnea is proximately due to OR aggravated (beyond a natural progression) by his service-connected hypertension? In so opining, the examiner must do the following: (i) consider the Veteran’s lay statements, to include his April 2015 statements contained in his notice of disagreement and testimony at the March 2020 Board hearing; and (ii) discuss the sleep articles (“Obstructive sleep apnea and hypertension: mechanisms, evaluation, and management”; “Sleep apnea”; “Obstructive sleep apnea and hypertension—an update”; and “Hypertension and obstructive sleep apnea”) referenced by the Veteran’s attorney in the March 2020 supplemental remarks (electronic links to articles provided therein). (continued on next page) All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Daley, 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.