Citation Nr: 21002114 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 15-35 582A DATE: January 12, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to hypertension, is remanded. REASONS FOR REMAND The Veteran had active service from October 1967 to October 1971. In June 2019, the Board remanded this matter to obtain a VA medical opinion as to whether the Veteran’s sleep apnea was caused by or aggravated by his service-connected hypertension. Although the Board regrets further delay, remand is again warranted to ensure that all due process requirements are met. Entitlement to service connection for sleep apnea, to include as secondary to hypertension is remanded. The Veteran contends that his current diagnosis of sleep apnea is secondary to his service-connected hypertension. Service connection may be established on a secondary basis for a disability that is proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) (2019); Allen v. Brown, 7 Vet. App. 439 (1995). The June 2019 remand requested that a VA examiner provide a medical opinion as to whether the Veteran’s obstructive sleep apnea is at least as likely as not caused by or aggravated beyond its natural progression by service-connected hypertension, including medications for hypertension. In November 2019, a VA examiner found that the Veteran’s sleep apnea was not caused by his hypertension. The VA examiner reasoned that, while sleep apnea can cause hypertension, hypertension cannot cause sleep apnea. The examiner did not provide an opinion regarding aggravation because the examiner could not establish a baseline level of severity. To support this conclusion, the examiner provided the same rationale as for the issue of causation. However, the Court of Appeals for Veterans Claims has held that causation and aggravation are independent concepts and should have separate findings and rationales. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The Board finds that a new VA medical opinion is necessary to determine whether the Veteran’s sleep apnea was caused by or aggravated by the Veteran’s service-connected hypertension. On remand, the VA examiner should consider a letter and accompanying medical articles submitted by the Veteran’s private physician in July 2020. The medical articles suggest that hypertension may cause or worsen sleep apnea. The private physician found the evidence “shaky” at best, but recommended assistance from a specialist in sleep medicine. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s sleep apnea is at least as likely as not proximately due to service-connected hypertension, or aggravated beyond its natural progression by service-connected hypertension, including medication for hypertension. (a.) The examiner must consider the medical article submitted by the Veteran in November 2015, entitled “High Blood Pressure Linked to Sleep Apnea.” (b.) The examiner must consider the letter submitted by the Veteran’s private physician in July 2020, with accompanying medical articles entitled “Sleep Apnea and High Blood Pressure: A Dangerous Pair” and “Relationship between OSA and High Blood Pressure.” (c.) The examiner must consider the medical articles submitted by the Veteran in July 2020, entitled “Obstructive Sleep Apnea and Hypertension” and “New Guideline Redefines High Blood Pressure, Considers Sleep Apnea.” (d.) The VA examiner must provide separate findings and rationales relating to causation and aggravation. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Casey 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.