Citation Nr: 21067161 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 16-56 758 DATE: November 3, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 2002 to November 2003. The Board previously remanded the issue of entitlement to service connection for a sleep disorder, to include obstructive sleep apnea, in August 2019 for additional development. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. The Veteran contends that he suffers from a sleep disorder, namely obstructive sleep apnea (OSA), that is related to his military service and, therefore, seeks service connection. The Board notes, at the outset, that the Veteran originally filed a claim for a sleep disorder, which was later separated into two claims for service connection for OSA and chronic fatigue syndrome (CFS). During the pendency of the appeal, the Veteran was granted service connection for CFS. VA medical records show that in July 2005 the Veteran reported having started sleep walking and talking in his sleep. In February 2009, he complained of sleeping difficulties and reported that he did not sleep as well without alcohol. A May 2014 home sleep study report shows that the Veteran was diagnosed with OSA and is prescribed a CPAP machine. The Veteran's service treatment records (STRs) show that on his October 2003 Post-Deployment Health Assessment he indicated "Yes During" the deployment that he experienced still feeling tired after sleeping. He did not respond in the "Yes Now" option. An August 2014 letter written by the Veteran's VA primary care provider, L.K., NP, enumerated the Veteran's medical history encounters for complaints concerning sleep problems and fatigue as: July 2005, sleep walking; February 2009, insomnia; April 2010, awakening in sleep, snoring, and the report of experiencing sleep disorder after service; May 2010, normal sleep study but positive for snoring; June 2010, trial on Ambien and prescription of trazadone; January 2013, fatigue; June 2014, positive sleep study. In a December 2014 statement in support of claim, the Veteran's wife stated that they married in 1991. She stated that the Veteran's snoring started shortly after the Veteran returned home from service. She stated that the snoring would rattle the dishes in the kitchen downstairs underneath their bedroom. She stated that the use of the CPAP machine has helped with symptoms. In June 2016, the Veteran was afforded a VA examination for sleep apnea, during which he reported onset of fatigue around 2003, seeking health care advice after release from service. His use of CPAP was noted, and the Veteran reported experiencing persistent daytime hypersomnolence. The examiner opined that it was less likely as not that the Veteran's sleep apnea was related to military service. In an August 2019 remand, the Board found the June 2016 examination to be inadequate and the Veteran was afforded a new VA examination in December 2019. The examiner noted the 2014 diagnosis of OSA and CPAP use. The examiner opined that the Veteran's OSA was less likely than not incurred in or caused by service. However, in his rationale, the examiner noted that the Veteran's symptoms of snoring, fatigue, and insomnia could be due to a myriad of causes, including his CFS. The Board notes that in the same opinion, the December 2019 VA examiner opined that the Veteran's CFS was related to his military service. Service connection for CFS was granted on this basis in a June 2020 rating decision. Given the examiner's statement that the Veteran's OSA symptoms may be due to the Veteran's now service connected CFS, an inference has been raised that the Veteran's OSA could be granted on a secondary basis. An addendum opinion addressing the theory of secondary service connection is necessary. The matter is REMANDED for the following action: 1. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran's obstructive sleep apnea. The entire claims file must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. After reviewing the claims file, (and the Veteran if indicated) the clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that the Veteran's obstructive sleep apnea had its origin in service or is related to the Veteran's active service. b. Whether it is at least as likely as not that the Veteran's obstructive sleep apnea was caused by the Veteran's service-connected disabilities, to include chronic fatigue syndrome. c. Whether it is at least as likely as not that the Veteran's obstructive sleep apnea was aggravated beyond its natural progression by the Veteran's service-connected disabilities, to include chronic fatigue syndrome. The rationale for any opinion expressed should be provided. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. The examiner should specifically address the Veteran's contentions and lay statements regarding onset of symptomatology and any continuity of symptomatology since discharge from service or since onset of symptomatology. It should be noted that lay persons are competent to attest to factual matters of which he or she had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran or other layperson, the examiner(s) should provide a fully reasoned explanation. All prior reports should be addressed and/or reconciled as necessary, to include the December 2019 VA opinion and rationale. 2. After the development requested has been completed, the examination reports should be reviewed to ensure that they are in complete compliance with the directives of this remand. If any report is deficient in any manner, corrective procedures should be implemented. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Sneeringer, 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.