Citation Nr: 21003418 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 13-26 248 DATE: January 21, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1988 to December 1991. This appeal was previously before the Board in July 2017, at which time it was remanded for further development. In a June 2018 decision, the Board denied the Veteran’s claim. That denial was subsequently appealed by the Veteran to the United States Court of Veterans Claims (Court). In a January 2019 Order, pursuant to a Joint Motion for Remand (JMR) filed by the parties, the Court vacated and remanded the June 2018 decision back to the Board. In July 2019, the Board remanded the claim for further development. Unfortunately, as pointed out by the Veteran’s representative, remand is again necessary. The Veteran claims entitlement to service connection for sleep apnea, to include as secondary to his service-connected PTSD. On remand, the agency of original jurisdiction (AOJ) was instructed by the Board to obtain a medical opinion addressing all theories of entitlement. A July 2019 reviewing clinician opined against a relationship between the Veteran’s sleep apnea and the Veteran’s service, as well as to his service-connected PTSD. With respect to the potential relationship to PTSD in particular, although the examiner concluded that the Veteran’s PTSD did not cause or aggravate the Veteran’s sleep apnea, the examiner’s rationale focused almost exclusively on causation, and not aggravation. As these are separate medical questions, an addendum opinion must be provided that more completely addresses both matters. In addition, as pointed out by the Veteran’s representative, although the Board acknowledged the Veteran’s assertion that service-connection may be warranted based on the presence of obesity as an “intermediate step” between the Veteran’s PTSD and sleep apnea in the body of its prior Remand, no specific question concerning this theory was asked of the VA reviewing clinician. The Board has outlined the questions below, and they too should be answered in an addendum opinion. The matters are REMANDED for the following action: 1. Obtain a medical opinion from a clinician other than the July 2020 opinion provider, addressing the etiology of the Veteran’s sleep apnea. The claims file should be sent to, and reviewed by the clinician. If in the opinion of the reviewing clinician the questions below cannot be answered without an in-person or virtual examination or interview, such should be scheduled. Upon review of the file, the clinician is asked to respond to each of the following: (a.) Is it at least as likely as not that (50 percent probability or more) the Veteran’s service-connected PTSD caused or aggravated the Veteran’s sleep apnea? Please keep in mind these are two separate inquiries, and supporting rationale must discuss both causation and aggravation. In providing a response to the question above, the examiner should also specifically address whether it is at least as likely as not that obesity served as an “intermediate step” between the PTSD disability and sleep apnea, answering the following questions: (i.) Is it at least as likely as not that the Veteran’s PTSD caused the Veteran to become obese or aggravated his obesity? (ii.) If so, was the obesity that resulted from, or was aggravated by the Veteran’s PTSD a substantial factor in causing sleep apnea? (iii.) Would the sleep apnea not have occurred, but for the obesity caused by or aggravated by the service-connected PTSD? All opinions should be supported by a medical explanation or rationale. 2. Then, readjudicate the issues on appeal. If the benefit sought remains denied, send the Veteran and his representative a Supplemental Statement of the Case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Bristow Williams, 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.