Citation Nr: 21004896 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 16-49 170 DATE: January 28, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1987 to November 1991, from April 1993 to July 1996, from January 1998 to February 2000, and from June 2002 to April 2003. He also had active duty for training from October 2000 to February 2001. This claim was previously before the Board in November 2019 and reopened based on new and material evidence, but then ultimately denied on its underlying merits. In response, the Veteran appealed to the higher U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC). In a September 2020 Order, the Court vacated the portion of the Board's decision that had denied this claim and remanded it back to the Board for further development and readjudication pursuant to agreement in a Joint Motion for Partial Remand (JMPR). The Board, in turn, is remanding this claim back to the local regional office (RO), i.e., Agency of Original Jurisdiction (AOJ).   Service connection is in effect for an acquired psychiatric disorder (including posttraumatic stress disorder (PTSD) and depression), also for degenerative disc and joint disease of the thoracolumbar spine with radiculitis, and for tinnitus and bilateral hearing loss. In a recent December 2020 brief, the Veteran’s attorney indicated the Veteran has been prescribed the following medications for his service-connected disabilities: Sertraline, Gabapentin, Trazodone, Meloxicam, Lamictal, and Wellbutrin. Pursuant to agreement in the JMPR, additional medical comment is needed concerning whether some of these medications aggravate the Veteran’s sleep apnea to, in turn, establish his entitlement to service connection for his sleep apnea as secondary to service-connected disability. 38 C.F.R. § 3.310(a) and (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). A January 2013 VA examination report includes the opinion of the examiner that the Veteran’s prescribed medication for his low back pain is less likely than not the cause of his sleep apnea, or that the medication makes it worse. The examiner considered the Veteran’s Hydrocodone, Tramadol, and Meloxicam. A June 2015 VA Disability Benefits Questionnaire (DBQ) examiner opined that the Veteran’s sleep apnea is less likely than not related to his service-connected acquired psychiatric disorder. The examiner’s rationale was that PTSD is not a known cause of sleep apnea, and there is no credible evidence in medical literature supporting any causative connection between PTSD and central sleep apnea. Further, Trazodone has been prescribed for treatment of the Veteran’s acquired psychiatric disorder, however, according to the VA examiner, it is not a high enough dose to cause central sleep apnea. Additionally, the Trazodone was not prescribed until after the Veteran was diagnosed with central sleep apnea, so by logical deduction it cannot be the source of his central sleep apnea. The 2015 examiner did not provide rationale with regard to whether Trazodone aggravates the Veteran’s sleep apnea; thus, a supplemental opinion is needed concerning this additional possibility.   Supplemental medical comment also is needed to address whether Sertraline, Gabapentin, Lamictal, and/or Wellbutrin cause and/or aggravate the Veteran’s sleep apnea. In rendering an opinion concerning this, the examiner should specifically consider when the Veteran was prescribed these medications, the dosage of the medications, whether the Veteran’s sleep apnea increased in severity while taking the medications, and if any increase was due to the natural progression of sleep apnea, his age, or his weight or body habitus or gender. Accordingly, this claim is REMANDED for the following additional development and consideration: 1. Obtain all VA clinical records for the Veteran from September 2015 to the present, to include a list of his prescribed medications. 2. Thereafter, obtain a supplemental opinion to the June 2015 DBQ opinion. The examiner is asked to specifically opine on the following: (A) Is it as likely as not (50 percent or greater probability) that Trazodone aggravates (worsens) the Veteran’s sleep apnea? (B) Is it as likely as not (50 percent or greater probability) that any of the following other medications: Sertraline, Gabapentin, Lamictal, and/or Wellbutrin, caused the Veteran’s sleep apnea? (C) Is it as likely as not (50 percent or greater probability) that any of the following medications: Sertraline, Gabapentin, Lamictal, and/or Wellbutrin, alternatively aggravates (worsens) the Veteran’s sleep apnea? Regarding aggravation, if it is as likely as not that the Veteran’s medication for a service-connected disability aggravates (worsens) his sleep apnea, the examiner should state, if feasible, the degree of worsening (i.e., the baseline of the disability before aggravation in comparison to the degree of severity after aggravation). In rendering an opinion, the examiner should specifically consider when the Veteran was prescribed these medications, the dosages of the medications, whether the Veteran’s sleep apnea increased in severity while taking the medications, and if any increase was due to the natural progression of sleep apnea, his age, or his weight or body habitus or gender. When responding, regardless of whether favorably or instead unfavorably, it is essential the examiner provide rationale – preferably citing to evidence in the file supporting conclusions and/or accepted medical authority. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Wishard 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.