Citation Nr: 21067655 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 14-11 117 DATE: November 4, 2021 REMANDED The issue of entitlement to service connection for a left bundle branch block (LBBB) disability, to include as secondary to service-connected obstructive sleep apnea (OSA), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from August 1972 to August 1974, and from December 1990 to July 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing in June 2014. Following a July 2014 remand of the claim of entitlement to service connection for a LBBB disability, the Board issued a decision denying the claim in March 2018. Thereafter, the Veteran appealed the March 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In December 2018, the Court issued an Order vacating and remanding the case pursuant to the terms agreed to by the parties in a Joint Motion for Remand (JMR). In July 2019, the Board remanded the claim for additional evidentiary development. Subsequently, the Veterans Law Judge (VLJ) who held the June 2014 Board hearing retired. In September 2021, the Board sent the Veteran a notice letter informing him that the judge who held his hearing was no longer employed at the Board and offering him the opportunity for a new hearing. He did not respond. Thus, the Board assumes that the Veteran does not want another hearing and will proceed with its appellate review of the case. Entitlement to service connection for a LBBB disability, to include as secondary to service-connected OSA. The Veteran contends that his LBBB disability was caused or aggravated by his now service-connected OSA. The Veteran has not contended, and the medical evidence of record does not suggest, that his LBBB had its onset in or is otherwise related to active service. Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) competent evidence establishing that the service-connected disability caused or aggravated the nonservice-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). During the Veteran's June 2014 Board hearing, Dr. R.R. testified that there are numerous cardiac manifestations of sleep apnea and one of the cardiac manifestations are palpitations and palpitations can come from numerous issues, including the left bundle branch block. Dr. R.R. also stated that he had no way of knowing how long the Veteran had a LBBB, but that there was a known association between sleep apnea and LBBB. In July 2019, the Board remanded the matter for a VA examination to ascertain whether the Veteran's LBBB disability was at least as likely as not (50 percent or greater probability) caused or aggravated by his sleep apnea. In rendering an opinion, the examiner was asked to address Dr. R. R.'s statements related to a known association between sleep apnea and a bundle branch block. In June 2021, the Veteran was afforded a VA heart conditions examination. In July 2021, the VA examiner provided the following medical opinion addressing the etiology of the Veteran's LBBB disability: After performing a physical exam and reviewing [the] medical records, it is 'less likely than not' that the Veteran's LBBB was aggravated by military service [or] sleep apnea. There [is] no medical literature showing that sleep apnea would aggravate or lead to LBBB. Dr. R.R.'s statements related to a 'known association' between sleep apnea and [LBBB] [are] not a medical literature study. In a follow-up statement, the examiner clarified, "After review of the medical records and performing a physical exam, it is 'less likely than not' that the Veteran's LBBB condition is proximately due to or the result of [the] service-connected sleep apnea condition since there is no medical pathophysiologic relationship between the sleep apnea causing or leading to [LBBB] since they are both anatomically and different physiological systems." The examiner further indicated, "Dr. R.R.'s statements relate to a known association between sleep apnea and a [LBBB], however, Dr. R.R. has no medical literature basis to make this statement as there are no studies that show there is a correction between the two conditions." Regrettably, the Board finds that the VA examiner's July 2021 medical opinion is inadequate and that a supplemental medical opinion is needed. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In particular, the July 2021 VA examiner's statement that "[t]here [is] no medical literature showing that sleep apnea would aggravate or lead to LBBB" does not adequately address the Veteran's specific case (versus generic medical literature) nor does it adequately address the causation or aggravation prongs of secondary service connection. The examiner's negative opinion is based solely on the fact that medical literature does not support a causal relationship or demonstrate aggravation of a nonservice-connected disability by a service-connected disability. The examiner does not indicate what medical literature was consulted in providing the opinion nor does the examiner actually explain why (from a pathological standpoint) the Veteran's obstructive sleep apnea does not cause or aggravate his LBBB disability. Furthermore, other than indicating the obvious that Dr. R.R.'s statements were not the equivalent of a medical literature study the examiner did not provide any indication why the Board should doubt the validity of his opinion on the "known association" between sleep apnea and LBBB. The VA examiner's opinion focused on the lack of a correlation between the two conditions because they affect "different physiological systems." However, the examiner did not provide a medical explanation other than lack of supporting medical literature regarding why LBBB was not proximately caused by or due to his service-connected OSA. Lastly, the VA examiner's opinion merely provided conclusory statement regarding "no aggravation" but did not adequately explain why the Veteran's LBBB was not aggravated beyond its natural progression by his service-connected OSA. See El-Amin v. Shinseki, 26 Vet. App. 136, 139 (2013) (holding that a VA examination does not adequately address aggravation unless it rules out the possibility of aggravation); see also Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009) (holding that a medical opinion finding no nexus based solely on medical literature is inadequate because it provides no discussion into the claimant's specific risk factors and circumstances of service). This matter is REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding medical records and associate them with the claims file. If possible, the Veteran himself should submit any pertinent new evidence regarding the condition at issue in order to expedite the claim. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's LBBB. Following a complete review of the electronics claims file, including a copy of this REMAND, the VA examiner is requested to opine as to the following: a. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's LBBB is proximately caused by his service-connected OSA. b. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's LBBB is aggravated beyond its natural progression by his service-connected OSA. "Aggravated" means having caused any increase in severity that is beyond the normal progression of the disability. The examiner must provide adequate rationale in support of all medical conclusions reached. If the examiner relies on medical literature to reach a medical conclusion, the examiner must cite the relevant literature and/or medical study and provide a summary of the findings. 3. After undertaking any other appropriate development deemed necessary, readjudicate the issue on appeal based on the additional evidence of record. If the determination remains adverse to the Veteran, he must be provided with a supplemental statement of the case (SSOC). An appropriate period of time must then be allowed for a response before the record is returned to the Board for further review. CONTINUED ON NEXT PAGE John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael L. Marcum, 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.