Citation Nr: 21065309 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 15-15 136 DATE: October 25, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2002 to July 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2018. A transcript of the proceeding is of record. The Board remanded the case for further development in June 2018 and October 2019. The case has been returned to the Board for appellate review. Upon review, the Board finds that further development is needed prior to adjudication of the claim. A January 2020 VA examiner opined that the Veteran's sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that there are lay statements indicating that the Veteran stopping breathing while sleeping in service; however, she stated that apnea and snoring that alone are not diagnostic of obstructive sleep apnea. She indicated that some apnea during sleep is normal and that a diagnosis of obstructive sleep apnea requires a threshold to be met, which was not identified in this case until December 2012, many years after his military service. Therefore, the examiner concluded that it is less likely than not the subjective symptoms noted in service were due to obstructive sleep apnea. The January 2020 VA examiner also opined that the Veteran's sleep apnea was less likely than not proximately due to or the result of his service-connected PTSD. She noted that, based on a review of medical literature, a cause-and-effect relationship has not been established between PTSD and obstructive sleep apnea. She explained that obstructive sleep apnea is a physiologic condition where there is a mechanical obstruction of breathing in the oropharynx during sleep that leads to deoxygenations and arousals that are so frequent and of such severity as to cause symptoms. PTSD is a mental health condition, which does not affect the oropharynx and thus would not cause a person to develop obstructive sleep apnea. In addition, the examiner stated that there is no evidence that any specific medication causes obstructive sleep apnea to develop. She further noted that the Veteran began treatment for PTSD in 2012 and that he was already obese at that time. She commented that, although some PTSD medications can cause a small degree of weight gain, the medications that he has been prescribed are not linked to causing obesity to develop independently. Therefore, the examiner concluded that it is less likely than not the Veteran's obstructive sleep apnea is proximately due to or caused by the service-connected PTSD, to include any medications to treat PTSD. Nevertheless, the July 2020 VA examiner did not separately address whether the Veteran's service-connected PTSD may have aggravated his sleep apnea. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013); Atencio v. O'Rourke, 30 Vet. App. 74 (2018) (finding a medical opinion inadequate because it did not address aggravation and causation separately with rationale specific to those findings). Therefore, the Board finds that an additional medical opinion is needed. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for sleep apnea that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also request any outstanding VA treatment records. 2. The AOJ should refer the Veteran's claims file to a VA examiner for a medical opinion as to the etiology of the Veteran's obstructive sleep apnea. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran and other laypersons are competent to attest to factual matters of which they have first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran or another layperson, the examiner should state this with a fully reasoned explanation. The examiner should state whether it is at least as likely as not that the Veteran's sleep apnea manifested in service or is otherwise causally or etiologically related to his military service, to include any symptomatology therein. The Veteran has reported that he had symptoms in service, such as impaired sleeping and difficulty breathing while sleeping. The examiner should address whether such symptoms may have been indicative of sleep apnea that was subsequently confirmed with a diagnosis. The examiner should also provide an opinion as to whether it is at least as likely as not that the Veteran's obstructive sleep apnea was either caused by or aggravated by his service-connected PTSD. The Veteran has claimed that his sleep apnea is secondary to his service-connected PTSD, to include the medications used to treat the disorder and resulting weight gain. In rendering this opinion, the examiner should state whether it is at least as likely as not that the Veteran's service-connected PTSD and the medications used to treat the disability caused him to gain weight or become obese. If so, the examiner should provide an opinion as to whether the weight gain or obesity was a substantial factor in causing the Veteran's sleep apnea. He or she should also provide an opinion as to whether the Veteran's sleep apnea would not have occurred or worsened but for the weight gain caused by his service-connected PTSD and medications. The examiner should specifically address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran's PTSD did not cause his current sleep apnea, the examiner should still address whether his PTSD could have worsened his sleep apnea, including any medications used to treat PTSD. 3. The examiner should further note that the aggravation prong of secondary service connection requires a worsening of the claimed disorder, but not a permanent worsening of the claimed disorder. The law provides that compensation is due for any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, in a nonservice-connected disability resulting from a service-connected disability, regardless of its permanence. In rendering his or her opinions, the examiner should consider the medical literature submitted by the Veteran addressing the relationship between psychiatric disabilities and sleep apnea and explain the significance of any literature as it applies to the Veteran's particular case. See March 2018 correspondence. He or she should also consider the Veteran's testimony regarding his symptoms during service, including snoring and choking, as well as the lay statements submitted on his behalf. See March 2018 Board hearing transcript; July 2015 correspondence. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions must be provided, and a discussion of the facts and principles involved would be of considerable assistance to the Board. 4. After completing these actions, the AOJ should ensure compliance with the remand directives and take any corrective action needed. 5. The AOJ should conduct any other development that may be indicated. J.W. ZISSIMOS 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.