Citation Nr: 21063618 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-41 432 DATE: October 14, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In the Substantive Appeal, the Veteran asked for a hearing before the Board by live videoconference at a local VA office. However, he later withdrew his request. 38 C.F.R. § 20.704(e). 1. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. 2. Entitlement to service connection for hypertension is remanded. The Secretary must provide an exam or medical opinion when it "is necessary to make a decision on the claim." 38 C.F.R. § 5103(d). A medical exam or opinion is necessary if the record contains (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that the veteran suffered an in-service event, injury, or disease; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to decide on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The third element "requires only that the evidence 'indicates' that there 'may' be a nexus" between the Veteran's symptoms or disability and his military service. McLendon, 20 Vet. App. at 83. "This is a low threshold." Id. Starting with the Veteran's sleep apnea claim, he underwent a diagnostic sleep study in July 1999. The results showed severe obstructive sleep apnea. More recent studies show that he continues to suffer from the sleep disorder. During service, the Veteran's spouse reported that his snoring was "always a problem." So much so that his fellow servicemembers threw their boots at him in the barracks. After service, his symptoms continued, she says, and eventually worsened. Consistent with this, the Veteran told his doctor in June 1999 (and well before the current claim) that he had been snoring loudly for about 30 years. White v. Illinois, 502 U.S. 346, 356 (1992) ("[A] statement made in the course of procuring medical services, where the declarant knows that a false statement may cause misdiagnosis or mistreatment, carries special guarantees of credibility."). "[E]vidence that 'indicate[s]' that a current disability 'may be associated' with military service include[s] . . . credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation." McLendon, 20 Vet. App. at 83. Because the record lacks sufficient competent medical evidence to decide the claim, the Board finds the criteria for a medical examination met. Moving on to the Veteran's hypertension claim, his VA medical records show a hypertension diagnosis during the appeal period, and the earliest medical record in the claims filea February 1998 private treatment recordnotes a history of hypertension. At entry, the Veteran reported a medical history of high blood pressure. On exam, his blood pressure measured 128 over 88, and the entry examiner found his heart to be clinically normal. At exit, not much had changed. The Veteran again reported a history of high blood pressure, his blood pressure measured 126 over 76, and the exit examiner found his heart to be clinically normal. Years later, the Veteran's spouse also reported that he had high blood pressure when he entered service. Based on this, the Board finds a medical opinion needed on whether the Veteran's hypertension pre-existed service. Two final notes. First, in February 2017, the Veteran authorized the release of medical records from Evans Army Community Hospital. Although he listed the medical provider or facility on the form, he left the treatment dates blank. The RO took no action. On remand, the RO should ask the Veteran for the missing information to ensure the record is complete and follow up as necessary. Second, as the case is being remanded for additional development, any outstanding VA treatment records should be associated with the claims file. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (per curiam). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Ask the Veteran to submit a VA Form 21-4142a, General Release for Medical Information for Evans Army Community Hospital. If returned, make as many requests as are necessary to obtain the relevant records and associate them with the claims file. If the RO concludes that the records sought do not exist or that further efforts would be futile, the claims file must be properly documented as to the unavailability of those records. 3. Then, schedule the Veteran for a VA examination to determine the nature and likely etiology of his obstructive sleep apnea. The claims file should be made available to and reviewed by the examiner. All necessary diagnostic testing should be accomplished. The examiner should provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that the Veteran's OSA had its clinical onset during service or is due to an event or incident of the Veteran's period of active service. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinion. However, if there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's statements or recollection are inconsistent with the evidence in this case, medical principles relating to the onset and progress of the disease, the specific findings in the record, and/or your professional judgment. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Schedule the Veteran for a VA examination to determine the nature and likely etiology of his hypertension. The claims file should be made available to and reviewed by the examiner. All necessary diagnostic testing should be accomplished. The examiner should provide an opinion on whether the Veteran's high blood pressure clearly and unmistakably existed before his military service. (a.) If so, opine whether it is clear and unmistakable (i.e., undebatable) that his pre-existing high blood pressure was NOT aggravated (i.e., permanently worsened beyond the natural course of the disease) during service. (b.) If not, opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's hypertension had its clinical onset during service or is due to an event or incident of the Veteran's period of active service. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. If the Veteran's OSA is service connected, arrange for an appropriate healthcare provider to review the Veteran's claims file and provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that the Veteran's hypertension was (A) caused or (B) aggravated beyond its normal progression by his service-connected sleep apnea. Aggravation means an increase in disabilityany additional impairment of earning capacityof the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Canedy, 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.