Citation Nr: 21003176 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 16-61 846 DATE: January 19, 2021 REMANDED Service connection for a sleep disorder, to include sleep apnea, upper airway resistance syndrome, and insomnia, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2002 to April 2014. He was awarded the Iraq Campaign Medal with Campaign Star among other decorations. The Veteran testified before the undersigned Veterans Law Judge in June 2020. A transcript of the hearing is in the Veteran’s eFolder. 1. Service connection for a sleep disorder, to include sleep apnea, upper airway resistance syndrome and insomnia, is remanded. This issue is remanded to obtain outstanding VA treatment records, conduct a VA examination and obtain a VA medical opinion. During the hearing, the Veteran testified that while serving in Iraq during his first deployment as a military policeman (MP) he had missions at all hours of the day with Iraqis. He would become tired and fatigued during the missions and had a hard time sleeping more than 3 hours a night. Doctors told him that his sleep problems were just from his deployment and would work themselves out. As an MP, he was also a shift worker in the rear. During his second deployment in Iraq, his missions became longer during which the MPs could not sleep at all. Within a month of returning to Germany, he had a week during which he slept only 2 hours, 4 at most, during the entire week. He went to a German hospital where he was given sleep medicine and a sleep study was recommended. On base, the military did not want to give him a sleep study. He was already on a permanent profile, so he was told to take over the counter medications. Whenever an Army doctor would get ready to recommend a sleep study, the Veteran would change doctors and have to start the process all over. As a result, he was never given a sleep study during active service. The Veteran stated that he had submitted private medical records showing he sought treatment for sleep problems in November 2014. Private treatment records dated in September 2014 reflect that 6 months after separation from active duty the Veteran sought treatment for excessive sleepiness during the day (daytime somnolence), fatigue and snoring. A polysomnography (PSG) was conducted in October 2014. The Veteran’s PSG results resulted in a diagnosis of REM related and positional obstructive sleep apnea, and Upper Airway Resistance Syndrome with an AHI [apnea/hypopnea index] of 3.2. An October 2014 physical examination resulted in an assessment of sleep apnea, sleeping excessive, snoring, insomnia and obesity. A July 2015 VA Sleep Apnea Disability Benefits Questionnaire (DBQ) relates that the Veteran’s PSG did not meet VA disability criteria for obstructive sleep apnea, which was set at an AHI of 5 or more events per hour. Hence, the Veteran’s sleep apnea was unverified. At the same time, the examiner noted that the Veteran currently had findings, signs or symptoms attributable to sleep apnea, consisting of restless sleep. In August 2020, the Veteran submitted correspondence from the Director of the Sleep Medicine Program at the VA Tennessee Valley Healthcare System. The Director informed him that the results of the Veteran’s June 2020 sleep study test demonstrated a significant amount of respiratory events that would support a diagnosis of obstructive sleep apnea. The Board cannot make a fully-informed decision on this issue based on the current record. A VA medical opinion is required to determine whether sleep apnea is related to the complaints of sleep problems noted in the Veteran's service treatment records. A VA medical opinion is also required to determine whether the Veteran has any diagnosed sleep disorder other than sleep apnea, and if so whether the diagnosed sleep disorder is related to the complaints of sleep problems noted in his service treatment records. Finally, if the VA opinion provider determines that the Veteran does not have a diagnosed sleep disorder, the examiner should opine as to whether the Veteran’s sleep issues are an undiagnosed illness or a medically unexplained chronic multisymptom illness. the Board observes that Iraq, where the Veteran served, is included in the Southwest Asia theater of operations. 38 C.F.R. § 3.317(e)(2). The matter is REMANDED for the following action: 1. Obtain and associate with the Veteran’s eFolder copies of all outstanding VA treatment records, including the report of the June 2020 VA sleep study. 2. After the record is determined to be complete, schedule the Veteran for a VA medical opinion for his sleep disorder. The clinician must review the eFolder. a. The clinician should identify all known clinical diagnoses relating to sleep problems to which the Veteran’s complaints are medically attributable. b. For each chronic disorder diagnosed in responding to the above, and to include (i) sleep apnea; (ii) Upper Airway Resistance Syndrome; and (iii) insomnia, the clinician should offer an opinion as to whether it is at least as likely as not (a 50% or greater probability) that such disability was incurred in or had onset during active duty service. The clinician is requested to specifically consider and address the Veteran's service treatment records, which reflect attempts to obtain treatment for sleep problems due to his work schedule as an MP; and the October 2014 private PSG results and diagnosis of REM related and positional obstructive sleep apnea, and Upper Airway Resistance Syndrome with an AHI [apnea/hypopnea index] of 3.2, with an additional assessment of sleep apnea, sleeping excessive, snoring, insomnia and obesity. c. The clinician should state whether examination findings or other evidence support a finding of (i) an undiagnosed illness that includes objective signs and symptoms of complaints of sleep problems that cannot be attributed to known medical diagnoses or (ii) a medically unexplained multisymptom illness. The clinician must explain the rationale for all opinions, citing to supporting factual data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in-service and post-service symptom experiences. If the clinician cannot provide an opinion without resorting to speculation, the clinician should provide an   explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Davitian, 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.