Citation Nr: 21061524 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 17-02 608 DATE: October 4, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include due to exposure to environmental hazards and/or as secondary to service-connected sarcoidosis, is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1984 to May 1987 and October 1989 to October 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In July 2019, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In August 2020, the Board remanded the issues on appeal for additional development and the case now returns for further appellate review. As in August 2020, the Board observes that the Veteran has also perfected an appeal as to the issue of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, depression, and other specified trauma and stressor related disorder; however, as he has requested a Board hearing before a Veterans Law Judge in connection with such appeal, the matter will be the subject of a separate Board decision issued at a later date, if otherwise in order. 1. Entitlement to service connection for OSA, to include as due to exposure to environmental hazards consistent with his service in Southwest Asia, and/or secondary to service-connected sarcoidosis. As noted in the August 2020 remand, the Veteran contends that his currently diagnosed OSA had its onset in service, to include as a result of exposure to environmental hazards coincident with his service in Southwest Asia, or is caused or aggravated by his service-connected sarcoidosis. At such time, the Board found that, in light of the current diagnosis of OSA as evidenced by a January 2011 sleep study, the Veteran's and his spouse's reports of in- and post-service sleep-related symptoms, his documented service in Southwest Asia, and his award of service connection for sarcoidosis, a remand was necessary in order to obtain an opinion addressing the etiology of such disorder. Specifically, the Board directed that a VA examiner review the record and offer opinions as to whether the Veteran's OSA had its onset in, or is otherwise related to, his military service, to include his exposure to environmental hazards coincident with his service in Southwest Asia, or whether such is caused or aggravated by his service-connected sarcoidosis. In this regard, the examiner was advised to consider the Veteran's statements as to his in-service symptomatology, and was advised that the sole basis for a negative nexus opinion may not be the fact that his service treatment records (STRs) were silent for any complaints, treatment, or diagnosis referable to OSA. In September 2020, a VA examiner reviewed the record and opined that the Veteran's OSA was less likely than not related to his military service, to include environmental factors, or his service-connected sarcoidosis. Rather, he found that such disorder was more likely related to his morbid obesity and increased neck size. In this regard, the examiner explained that morbid obesity, increased neck size, and OSA are closely related and due to intermittent obstruction of the upper airway during sleep because of excess fat deposition in the upper pharyngeal and soft palate area. He further noted that there was no evidence of airway obstruction or blockage at the time his bronchoscopy. As a final matter, the examiner indicated that he disagreed with the award of service connection for sarcoidosis as related to his in-service exposure to environmental hazards. However, as the examiner did not consider the Veteran's statements regarding his relevant in-service symptomatology, or address whether his OSA is aggravated by his sarcoidosis, as directed by the August 2020 remand directives, another remand is necessary in order to obtain an addendum opinion addressing such matters. Stegall v. West, 11 Vet. App. 268, 271 (1998). 2. Entitlement to service connection for hypertension. As noted in the August 2020 remand, the Veteran contends that his currently diagnosed hypertension had its onset during service as he had elevated blood pressure readings and began taking over-the-counter medication therein, and such was the result of the anxiety and stress associated with his in-service duties as a medic, to include one incident where he cared for a fellow soldier who ultimately died, and finance officer. At such time, the Board found that, in light of the Veteran's STRs demonstrating his report of higher or low blood pressure at the time of his entrance to his second period of active duty on a June 1989 Report of Medical History with a notation of a prior high blood pressure reading on a single occasion and elevated blood pressure readings in June 1992, his report of relevant symptomatology during and since service, and his current diagnosis of hypertension, a remand was necessary in order to obtain an opinion addressing the etiology of such disorder. Specifically, the Board directed that a VA examiner review the record and offer an opinion as to whether the Veteran's hypertension had its onset in, or is otherwise related to, his military service, to include his occasional high blood pressure reading as documented in June 1992 and informally reported by him and/or the anxiety and stress associated with his in-service duties, or manifested within one year of his separation from service in May 1987 or October 1993. In January 2021, a VA examiner reviewed the record, interviewed the Veteran, and conducted a physical examination, and opined that his hypertension was less likely than not incurred in or caused by the anxiety and stress associated with his duties as medic during service. In this regard, she noted that, while the Veteran reported one elevated blood pressure reading in the past on his June 1989 Report of Medical History, such reading was not documented in his STRs and one high reading does not meet the criteria for hypertension. Additionally, the examiner observed that he had elevated blood pressure readings on two occasions in June 1992, but found that such were likely secondary to his contemporaneous acute varicella infection. She also observed that, while the Veteran reported that he had additional elevated blood pressure reading when informally taken by a fellow medic, it was likely that, if his blood pressure was persistently elevated, his fellow medic would have sent him for further evaluation and treatment. Rather, the first post-service blood pressure reading was recorded in 2007 when it was slightly elevated, and he had been treated with medication for hypertension since 2010. Consequently, the examiner found that, while the exact date of diagnosis of hypertension was unknown, it was sometime between 1993 and 2010. The examiner further determined that it was not likely that the Veteran's hypertension manifested within one year of his separation in May 1987 or October 1993. In this regard, she indicated that, as there was no evidence of hypertension during his second period of service, it was did not manifest within one year of his first separation in May 1987. The examiner further indicated that, as there were no records from the time period from 1993 to 2010, with the exception of the single aforementioned 2007 record, there was no evidence that hypertension manifested within one year of his second separation in October 1993. Nonetheless, she again indicated that the Veteran's hypertension was diagnosed between 1993 and 2010. However, the examiner offered conflicting findings as to the onset of the Veteran's hypertension, i.e., reporting the onset between 1993 and 2010, but finding that such did not manifest within one year of his separation from his second period of service in October 1993 (i.e., by October 1994), did not explain the basis for her opinion that the Veteran's hypertension was unrelated to anxiety and stress associated with his in-service duties beyond citing the lack of evidence of hypertension in his STRs, and did not address the Veteran's report of taking over-the-counter medication for hypertension during and since service. Thus, a remand is necessary in order to obtain an addendum opinion addressing such matters. The matters are REMANDED for the following action: 1. Forward the record, to include a copy of this Remand, to an appropriate VA clinician other than the September 2020 VA examiner to obtain an addendum opinion addressing the etiology of the Veteran's OSA. Following a review of the record, the clinician is requested to offer an opinion as to the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's OSA had its onset in, or was otherwise related to, his military service, to include exposure to environmental hazards consistent with his service in Southwest Asia? In offering such opinion, the examiner must consider and address the Veteran's report that he was always tired in the morning during service and his spouse's report that, when she met and married him in 2008, she witnessed his snoring and gasping for air. The examiner is advised that the sole basis for a negative nexus opinion may not be the fact that the Veteran's STRs are silent as to any complaints, treatment, or diagnosis of OSA. (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's OSA is caused or aggravated by his sarcoidosis? For any aggravation found, the examiner should state, to the best of his or her ability, the baseline symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 2. Forward the record, including a copy of this Remand, to the VA examiner who conducted the January 2021 examination for an addendum opinion addressing the etiology of the Veteran's hypertension. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension had its onset in, or is otherwise related to, his military service, to include his two documented high blood pressure readings in 1992 and/or his stress and/or anxiety associated with his in-service duties as a medic and finance officer? In offering such opinion, the clinician must consider and address the Veteran's report that he had elevated blood pressure readings, to include when informally taken by him and his fellow medics, and began taking over-the-counter medication therein, and experienced high levels of stress and anxiety while working as a medic, to include one incident where he cared for a fellow soldier who ultimately died, and finance officer. (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension manifested within one year of his separation from service either in May 1987 (i.e., by May 1988) or October 1993 (i.e., by October 1994)? If so, please describe the manifestations, to include indicating whether continuous medication was needed for control. In offering such opinion, the clinician must address the Veteran's statements regarding the onset and continuity of symptomatology of his hypertension. He or she is advised that the rationale for an unfavorable opinion cannot be based solely on the absence of documented evidence of hypertension or symptoms thereof during or after service. The examiner is also requested to reconcile her conflicting findings as to the onset of the Veteran's hypertension in the January 2021 opinion, i.e., reporting the onset between 1993 and 2010, but finding that such did not manifest within one year of his separation from his second period of service in October 1993 (i.e., by October 1994). A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Spielmann, Jill F. 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.