Citation Nr: 20034086 Decision Date: 05/15/20 Archive Date: 05/15/20 DOCKET NO. 16-47 018 DATE: May 15, 2020 REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for pulmonary hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from October 1964 to October 1966 and from November 1966 to August 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in January 2019, when it was remanded for Agency of Original Jurisdiction (AOJ) development. The case has been returned to the Board for further appellate review. 1. Entitlement to service connection for sleep apnea is remanded. In May 2018, the Veteran submitted an article discussing an association between obstructive sleep apnea and posttraumatic stress disorder (PTSD). The Veteran also submitted a private medical opinion, which noted this article and described the Veteran’s sleep apnea symptom of daytime somnolence as adversely affecting his anxiety. The private physician opined that it is as likely as not that the service-connected PTSD aided in the development and permanently aggravates the Veteran’s obstructive sleep apnea. However, the private physician did not explain how the principles in the article applied to the circumstances of the Veteran’s case, or how the coincidence of the two disabilities in the Veteran indicated that the service-connected PTSD caused the sleep apnea. In June 2019, the Veteran was afforded a VA sleep apnea examination. The VA examiner opined that the sleep apnea did not have its onset in and was not caused by active service, because the Veteran separated from the military in August 1986 and was diagnosed with sleep apnea in January 2005. The examiner further opined that current medical literature indicates no causative etiology between sleep apnea and PTSD, but did not address the article submitted by the Veteran, which suggested the possibility of a bi-directional causal relationship. As neither opinion in the record is fully sufficient regarding the etiology of the Veteran’s sleep apnea, a remand is necessary to obtain an adequate opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). 2. Entitlement to service connection for pulmonary hypertension is remanded. The Veteran attended a VA examination in conjunction with this claim in June 2019. The examiner opined that the pulmonary hypertension is less likely as not caused by active duty service, as he was initially diagnosed in 2006, 20 years after separating from the military. The examiner also opined that, as the Veteran’s treating cardiologist and pulmonologist diagnosed coronary artery disease in 2010, the coronary artery disease cannot have caused the pulmonary hypertension. To further support the conclusion, the examiner noted that the cardiologist and pulmonologist did not note a correlation between the coronary artery disease and the pulmonary hypertension. Evidence was then added to the record indicating the coronary artery disease was present prior to 2010, and the RO requested an addendum opinion. Another examiner reviewed the claims file in November 2019 and explained that there are three predominant variables involved in the development of pulmonary hypertension, including increased pulmonary venous pressure, which can be caused by left ventricle systolic or diastolic dysfunction. The examiner pointed to a recent echocardiogram showing a normal left ventricle size with ejection fraction of 55 percent to support the conclusion that the coronary artery disease is less likely as not to play a major etiological role in the pulmonary hypertension. However, the examiner failed to address the diastolic dysfunction noted in the Veteran’s private treatment records from when he was seeking treatment for dyspnea on exertion, and whether this is related to the service-connected coronary artery disease. In March 2020, the Veteran submitted a medical opinion from a private physician. The physician opined that the coronary artery disease is as likely as not a cause of the pulmonary hypertension, as the Veteran’s “significant cardiac conditions” are an important risk factor along with his other risk factors of emphysema, tobacco use, and obstructive sleep apnea. However, the examiner did not discuss the relationship of coronary artery disease to the Veteran’s other cardiac conditions, and whether the coronary artery disease alone is as likely as not the cause of the pulmonary hypertension. Therefore, as none of the opinions of record are sufficient, a remand is necessary to obtain an adequate opinion addressing whether the pulmonary hypertension is at least as likely as not caused by or proximately due to the service-connected coronary artery disease. Finally, the Board notes the November 2019 VA examiner and the private physician both stated that obstructive sleep apnea is a risk factor for pulmonary hypertension. In the event the development for the Veteran’s sleep apnea claim yields a favorable result, this theory of entitlement should be explored as well. The matters are REMANDED for the following action: 1. Forward the claims file to an appropriate clinician to determine whether the sleep apnea disability is related to the Veteran’s military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Where the examiner deems it appropriate, a telehealth or telephone interview is acceptable. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the sleep apnea began in or is otherwise caused by the Veteran’s active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that the sleep apnea is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran’s service-connected PTSD. Please note, causation and aggravation are separate concepts and must be addressed independently. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the sleep apnea prior to aggravation by the service-connected disabilities by medical record and/or the Veteran’s lay statements. The examiner should specifically address and discuss the Veteran’s lay statements regarding the onset of early sleep apnea symptoms, and the article submitted in May 2018 titled “Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort.” The examiner should address any other pertinent evidence of record. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 2. Forward the claims file to an appropriate clinician to determine whether the pulmonary hypertension disability is related to the Veteran’s military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the pulmonary hypertension began in or is otherwise caused by the Veteran’s active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that the pulmonary hypertension is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran’s service-connected coronary artery disease and/or the Veteran’s sleep apnea (if sleep apnea is found to be related to service). If aggravation is found, the examiner must attempt to establish a baseline level of severity of the pulmonary hypertension prior to aggravation by the service-connected coronary artery disease and/or the sleep apnea (if sleep apnea is found to be related to service). Please note, causation and aggravation are separate concepts and must be addressed independently. The examiner should specifically address the relationship between the service-connected coronary artery disease and the Veteran’s other cardiac conditions, including the diastolic dysfunction noted in the Veteran’s private treatment records. The examiner should address any other pertinent evidence of record. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Josey, 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.