Citation Nr: 21001384 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 16-48 095 DATE: January 7, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) to include as secondary to posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1987 to February 1990 and from February 2003 to July 2004, to include service in Southwest Asia during the Persian Gulf War. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision by the San Juan, Puerto Rico Regional Office (RO) of the United States Department of Veterans Affairs. This matter was previously before the Board, most recently in November 2019, at which time it was remanded for additional development. As discussed in more detail below, the Board finds that there was not substantial compliance with its November 2019 remand order and another remand of this issue is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). In its November 2019 remand directives, the Board requested an addendum opinion to determine etiology of the Veteran’s OSA. The requested opinion was directed to consider causation and aggravation of OSA, as due to PTSD to include the suggestion that the prescription medication benzodiazepine, which the Veteran takes for PTSD, caused or aggravated his OSA. A new opinion was obtained in November 2019. While the opinion found that it was less likely than not that the Veteran’s OSA was incurred in or caused by service, it did not specifically address OSA as secondary to the prescription medication the Veteran takes for PTSD, or as due to or aggravated by Gulf War environmental exposures, as was directed the Board. Additionally, the VA examiner provided no rationale for the finding that the Veteran’s OSA was not aggravated by PTSD. Therefore, a new medical opinion must be obtained to comply with the Board’s prior remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following action: 1. Return the file to the VA examiner who provided the November 2019 VA sleep apnea addendum opinion. The claims file must thoroughly be reviewed by the examiner. If the examiner is not available, another appropriate medical professional may be consulted. If the examiner determined another VA examination is necessary, one should be provided. The examiner must determine if it is at least as likely as not (50 percent or greater probability) that any currently diagnosed obstructive sleep apnea is at least as likely as not related to his active military service, to include the February 1990 report of frequent trouble sleeping and to include his presumed Gulf War environmental exposures. The examiner should also opine as to whether the Veteran’s currently diagnosed obstructive sleep apnea is at least as likely as not proximately due to or aggravated beyond its natural progression by the service-connected PTSD to include major depression disorder. In forming these opinions, the examiner must address the June 2015 Sleep Apnea DBQ, to include the suggestion that the prescription medication – benzodiazepine – the Veteran takes for his PTSD aggravated his obstructive sleep apnea. Additionally, recent studies indicating biochemical changes due to PTSD have neurological impacts on sleep disordered breathing. The role, if any, of exposure to environmental factors during the Gulf War must also be specifically discussed. A full and complete rationale for each opinion requested is required. 2. Then readjudicate the remanded issue. If the benefit sought remains denied, the Veteran and his representative should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Lunger, 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.