Citation Nr: 21061301 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 16-10 830 DATE: October 1, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD) with major depressive disorder, is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to PTSD with major depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1989 to September 1989 and from April 1990 to October 1999. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2014 and April 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The September 2014 rating decision denied service connection for hypertension, while the April 2016 rating decision denied service connection for OSA. In July 2018, the Veteran testified in a Board hearing. The undersigned Veterans Law Judge (VLJ) held the record open for 30 days to allow the Veteran time to supplement the record with additional lay and medical evidence. A copy of the hearing transcript is of record. The Board notes that regarding the claims for entitlement to service connection, the AOJ recorded a memorandum in September 2008 detailing Formal Findings of Unavailability of some of the Veteran's service treatment records (STRs). Additionally, email verification in March 2015 confirmed that the Veteran's STRs for the period April 1990 to October 1999 were unavailable. In cases where service treatment records are lost due to no fault of the Veteran, the Board has a heightened obligation to explain its findings and conclusions and to consider the benefit-of-the-doubt rule carefully. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The issues were previously before the Board in January 2019 and were remanded. The RO was mandated to afford the Veteran a supplemental medical opinion. In October 2019, VA examinations were procured. The Board, as is explained below, finds the examinations incomplete. Thus, there has not been substantial compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for hypertension is remanded. The Veteran contends that his hypertension is related to service. In the alternative, he avers that his service-connected PTSD with major depressive disorder may have caused and/or aggravated his hypertension. The Veteran was diagnosed with hypertension in October 2013. During a May 2014 VA hypertension examination, the examiner diagnosed hypertension. Additionally, the Veteran asserted during his July 2018 hearing, that he was diagnosed with hypertension "right after service" by his primary VA physician. The Veteran was afforded a VA examination in October 2019, wherein he reported a history of hypertension dating back to 2009 and due to his PTSD. The examiner provided a negative nexus to service and determined that the secondary causal relationship to PTSD was moot since the [t]hree BP today d[id] not meet the VA criteria for hypertension." As for aggravation, he noted that the Veteran's claimed hypertension had been aggravated (increased in severity beyond its natural progression) by his service-connected PTSD. Nonetheless, he refers to the above rationale that the criteria for hypertension were not met for the "[t]hree BP today d[id] not meet the VA criteria for hypertension." The Board finds this examination lacking and, therefore, incomplete, in light of the previous findings of record of the Veteran having had hypertension during the appeal period and his taking of Lisinopril to control it. Again, as there is no adequate medical opinion of record addressing whether the Veteran's service-connected PTSD caused and/or aggravated his hypertension, a remand is warranted for a supplemental medical opinion. Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to service connection for OSA is remanded. The Veteran contends that his OSA is related to service. In the alternative, he asserts that his service-connected PTSD with major depressive disorder may have caused and/or aggravated his OSA. The Veteran was diagnosed with OSA in October 2014. As previously mentioned, his STRs are unavailable. During a July 2018 Board hearing, he testified that when he came home from service, his wife told him that he "would be snoring and gasping for air while sleeping." He was later diagnosed with OSA. In an April 2017 statement, the Veteran contended that his PTSD has caused him to gain weight, which then caused his OSA. The Board notes that numerous VA treatment records describe the Veteran as being "overweight." During a July 2014 treatment entry, the clinician noted that the Veteran's "multiple sleeping symptoms, obesity makes [him] hi[gh] risk for this PTSD factor." The Veteran was afforded VA examination in October 2019. The examiner provided a negative opinion regarding whether the Veteran's OSA began during active service or related to an incident of service; whether it was proximately due to and/or aggravated by service-connected PTSD; whether the Veteran's service-connected PTSD caused him to become overweight, to include medications taken for the disability; and whether OSA would not have occurred, but for his service-connected PTSD. Specifically, addressing the direct service and secondary causation, the Board finds the explanation wanting. The examiner explained that after a review of the record and consultation with a renowned sleep specialist, it was determined that did not indicate that the Veteran had observed apneic episodes or choking, which are the two hallmarks that would suggest the presence of sleep apnea. As the examiner did not fully offer a complete rationale, a remand is again warranted for a supplemental opinion. The Board notes that it finds no issue with the findings and rationales for whether the Veteran's service-connected PTSD and medications taken therefor caused him to become overweight, and whether OSA would not have occurred, but for his service-connected PTSD and the opinions addressing the submitted articles. Accordingly, the matters are REMANDED for the following action: 1. Provide the Veteran's claims file to a qualified clinician so that a supplemental opinion may be provided for hypertension. A physical or telehealth examination of the Veteran is only required if deemed necessary by the clinician. The entire claims file and a copy of this remand must be made available to the clinician to review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. Treatment records, including VA examination of May 2014, noting a diagnosis of hypertension. b. July 2018 Board testimony. The clinician is asked to opine as to the following: a. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's hypertension began during active service, is related to an incident of service, or began within one year after discharge from active service. b. Whether it is at least as likely as not that the Veteran's hypertension was proximately due to or the result of service-connected PTSD with major depressive disorder. c. Whether it is at least as likely as not that the Veteran's hypertension has been aggravated (increased in severity beyond its natural progression) by his service-connected PTSD with major depressive disorder. 2. Provide the Veteran's claims file to a qualified clinician so that a supplemental opinion may be provided for his OSA. A physical or telehealth examination of the Veteran is only required if deemed necessary by the clinician. The entire claims file and a copy of this remand must be made available to the clinician to review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. Treatment notes dated April 03, 2008, and October 7, 2014, wherein the Veteran indicated that he did not smoke nor consumed alcohol. b. During a July 2014 treatment entry, the clinician noted that the Veteran's "multiple symptoms, obesity makes [him] hi[gh] risk for this PTSD factor." c. July 2018 Board testimony. d. The article received in September 2021 titled "PTSD and Sleep" from the publication PTSD Research Quarterly. The clinician is asked to opine as to the following: a. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran's OSA began during active service is related to an incident of service. b. Whether it is at least as likely as not that the Veteran's OSA was proximately due to or the result of service-connected PTSD with major depressive disorder. c. Whether it is at least as likely as not that the Veteran's OSA has been aggravated (increased in severity beyond its natural progression) by his service-connected PTSD with major depressive disorder. (Continued on the next page) The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. 3. Readjudicate the claims. Dorilyn Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, 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.