Citation Nr: 21004110 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 15-07 605 DATE: January 26, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected deviated septum, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from March 1971 to March 1975. The Veteran testified before the undersigned Veterans Law Judge (VLJ) during an April 2018 hearing, and a copy of the transcript is of record. This matter is on appeal from a July 2014 rating decision. In a July 2019 decision and remand, the Board of Veteran’s Appeals (Board) found that a March 2019 VA medical opinion was inadequate because it did not address the trauma the Veteran sustained to his face in combat in June 1972. Therefore, the Board remanded this issue to afford the Veteran a supplemental VA medical opinion. The Agency of Original Jurisdiction (AOJ) has done so, and readjudicated the case in a July 2020 Supplemental Statement of the Case (SSOC). In July 2019, the Board also remanded the issue of service connection for deviated septum residual of a broken nose claimed as a sinus condition. Service connection for this issue was granted in a July 2020 rating decision and that issue is no longer on appeal. Upon review, the Board finds that additional development is needed prior to adjudication of the claim. In February 2020, the Veteran was afforded a VA medical opinion regarding his sleep apnea. In July 2020, the RO granted service connection for deviated septum residual of a broken nose claimed as a sinus condition with an evaluation of 0 percent effective November 2013. Although the Veteran had not yet been granted service connection for his traumatic deviated septum at the time of the February 2020 VA medical opinion, the clinician addressed both direct and secondary service connection. The clinician found that the Veteran’s sleep apnea was not directly or secondarily service connected. However, the clinician’s analysis for secondary service connection is incomplete and a supplemental medical opinion is necessary. The clinician made note of a June 2014 VA examination that found that the Veteran has complete obstruction of the sinus on the left side due to his traumatic deviated septum. The clinician also acknowledged that at the April 2018 hearing, the Veteran testified that his left nostril is up to 75 to 87 percent blocked as a result of the trauma he sustained in service when his ship ran over sea mines in June 1972, which caused him to hit his face on a bulkhead. The Veteran stated that he believes this blockage has worsened his sleep apnea. The clinician also observed an April 2018 statement submitted by the Veteran’s shipmate, L.A.K., who wrote that he saw that the Veteran had a bloody face after he had been slammed against the bulkhead after they struck the mines in June 1972. This evidence is competent and credible. The clinician concluded that the Veteran’s traumatic deviated septum did not cause or aggravate his sleep apnea. In so finding, the clinician observed that the Veteran has Mallampati pharyngeal 3 to 4 noted along with elongated uvula. The clinician stated that this score refers to anatomy of the soft palate, tongue and uvula, and that this would create far more upper airway resistance than a deviated nasal septum. The clinician further explained that score three means that the tongue is covering most but not all of the uvula and that the airway is mostly closed, and score four means that the tongue is covering all of the uvula and the airway is very closed. The clinician stated that the Veteran’s records from the sleep clinic in 2009 make no mention of a traumatic deviated septum. Rather, the examiner at the sleep clinic noted that weight loss is encouraged as obesity is a well-documented risk factor for obstructive sleep apnea. Further, the clinician also stated that while upper airway resistance is also a risk factor for sleep apnea, a deviated septum with decreased airflow through one nostril would not result in significant resistance as the Veteran can still move air through the opposite nostril and mouth. The February 2020 medical opinion does not provide sufficient detail to warrant a finding that the Veteran’s traumatic deviated septum did not aggravate his sleep apnea. The clinician’s rationale addresses why the traumatic deviated septum did not cause the Veteran’s sleep apnea, but he did not explain why the traumatic deviated septum did not aggravate the condition. El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of “not due to,” “not caused by,” and “not related to” a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). To be adequate, a VA opinion must provide separate rationales for both the causation and aggravation prongs of a secondary service connection claim. Atencio v. O’Rourke, 30 Vet. App. 74 (2018). Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obliged to do so, it must provide one that is adequate for the purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 3030, 311 (2007). Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. A remand is necessary to afford the Veteran a supplemental medical opinion addressing the aggravation prong for secondary service connection. The matters are REMANDED for the following action: 1. Return the Veteran’s claims file to the clinician who provided the February 2020 medical opinion so a supplemental opinion may be provided. If that clinician is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. A new physical or telehealth examination is only required if deemed necessary by the clinician. The clinician must determine whether it is at least as likely as not that the Veteran’s sleep apnea was aggravated beyond its natural progression by his service-connected deviated septum. The clinician must provide a complete rationale of his or her opinion(s) in the examination report. 2. Ensure that the directive specified in this remand has been implemented. If it has not, appropriate corrective action must be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 3. Readjudicate the claim. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. DeVerter, Associate 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.