Citation Nr: 21003701 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 14-43 448 DATE: January 22, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1986 to January 1990, May 2008 to October 2008, and June 2010 to March 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in June 2014 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In July 2018 and September 2019, the Board remanded the matter for additional development and it now returns for further appellate review. In August 2020, the Veteran submitted additional evidence in consideration of his appeal. Entitlement to service connection for sleep apnea, to include as secondary to PTSD. In September 2019, the Board remanded the case in order to obtain an addendum opinion to determine if the Veteran’s currently diagnosed sleep apnea was aggravated by his service-connected PTSD. In this regard, while the Board previously found that a VA opinion obtained in October 2016 adequately addressed direct service connection and secondary service connection based on causation, such did not address secondary service connection based on aggravation. Furthermore, in September 2019, the Board found that a June 2019 addendum opinion did not adequately address such aspect of the Veteran’s claim. In this regard, the Board observed that, while the examiner opined that PTSD does not aggravate sleep apnea, she did not adequately explain why she came to such conclusion. Rather, she simply noted that, if the Veteran had been getting up in the middle of the night due to apnea and not nightmares, he may have an improper fitting CPAP or inadequate pressure for which he should speak to his treating physician. Thus, the Board again remanded the case in order to obtain an opinion addressing whether the Veteran’s sleep apnea was aggravated by his PTSD. In December 2019, the June 2019 VA examiner conducted a VA examination and offered an addendum opinion; however, she only addressed direct service connection and secondary service connection based on causation. No opinion regarding whether the Veteran’s sleep apnea was aggravated by his PTSD was offered. In January 2020, the Veteran was afforded another VA examination conducted by a different examiner and, in addition to addressing direct service connection and secondary service connection based on causation, she indicated that she could not determine a baseline level of severity of sleep apnea based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by PTSD. Specifically, the examiner reported that the medical evidence was not sufficient to support a determination of a baseline level of severity and current research was unable to support a rationale to determine a baseline level of severity. Nonetheless, she opined that, regardless of an established baseline, the Veteran’s sleep apnea was not at least as likely as not aggravated beyond its natural progression by his PTSD. However, the examiner provided an insufficient rationale for such opinion as she merely retired that the medical evidence was not sufficient to support a determination of a baseline level of severity and current research was unable to support a rationale to determine a baseline level of severity. Furthermore, subsequent to the December 2019 and January 2020 opinions, the Veteran reported in an August 2020 statement that he does not have issues with his CPAP mask, he wears it every night, it is not ill-fitting, and does not have leaking issues. He also submitted four new medical articles addressing the relationship between PTSD and sleep apnea and, in his December 2020 Written Brief Presentation, the Veteran’s representative cited two additional medical articles for similar propositions. Accordingly, the Board finds that a remand is necessary in order to obtain an addendum opinion that adequate addresses whether the Veteran’s sleep apnea is aggravated by his PTSD, which includes consideration of the aforementioned medical articles. The matters are REMANDED for the following action: Forward the record, to include a copy of this Remand, to an appropriate VA examiner so as to obtain an addendum opinion addressing the etiology of the Veteran’s sleep apnea. Following a review of the record, to specifically include the November 2017 submissions from Drs. W.J. and W.G., and the medical articles submitted by the Veteran in November 2017 and August 2020, and cited by his representative in his December 2020 Written Brief Presentation, the examiner should offer an opinion as to whether it is as least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s currently diagnosed sleep apnea is aggravated by his service-connected PTSD. Why or why not? If aggravation is found, examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In this regard, the examiner is advised that an opinion on direct service connection and secondary service connection based on causation is not needed. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Waite 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.