Citation Nr: 21068328 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 18-25 972 DATE: November 10, 2021 REMANDED Entitlement to service connection for sleep apnea to include as secondary to the Veteran's service-connected diabetes mellitus type II or post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1967 to September 1970 and from August 1974 to September 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2016 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). Sleep Apnea While the RO obtained a March 2018 medical opinion regarding the etiology of the Veteran's claimed sleep apnea disability, the Board finds it to be inadequate. The examiner indicated that the Veteran's PTSD and diabetes mellitus type II less likely than not (less than a 50 percent probability) cause or aggravate the Veteran's sleep apnea disability. In proffering their opinion the examiner noted that no objective medical literature links the Veteran's service-connected conditions with sleep apnea. Instead, the examiner linked the Veteran's sleep apnea to other factors, including obesity. However, the examiner did not discuss whether the Veteran's diabetes and/or PTSD, to include the medications taken in treatment thereof, caused the Veteran to become obese, or whether these service-connected conditions aggravated his obesity. The Board notes that obesity can be an "intermediate step" in a causal chain for service connection which can be established on either a causal or aggravation basis. See Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). Further, the Veteran specifically argued that his type II diabetes, PTSD, or the medication taken in treatment thereof caused him to gain weight. See May 2018 VA Form 9; see also October 2021 Appellant's Brief. As such, the Board finds that an additional medical opinion is necessary to determine the etiology of the Veteran's sleep apnea disability. The matters are REMANDED for the following action: Obtain a medical opinion, from a VA examiner, who has yet to examine the Veteran, with sufficient expertise to comment on the etiology of the Veteran's sleep apnea disability. All pertinent evidence of record must be made available to and reviewed by the examiner, including a copy of this remand. Any indicated studies should be performed. No additional examination is required unless the examiner deems it necessary. Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to the following: - Whether the Veteran's obesity was an intermediate step between his current sleep apnea and his service-connected diabetes and/or PTSD. The examiner should specifically state whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's diabetes and/or PTSD, to include the medication taken in treatment thereof, caused the Veteran to become obese or aggravated his obesity. - If so, the examiner must then opine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's obesity, or the aggravation of the obesity, as a result of either the Veteran's service-connected diabetes and/or PTSD was a substantial factor in causing the Veteran's sleep apnea, and whether the Veteran's sleep apnea would not have occurred but for the obesity caused or aggravated by the service-connected PTSD and/or diabetes. In proffering their opinion, the examiner must address the medical articles/treatises cited by the Veteran in his October 2021 Appellant's Brief. See Appellant's Brief pp. 4-5. The examiner must provide a complete rationale for all proffered opinions. In this regard, the examiner must discuss and consider the Veteran's competent lay statements. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Gresham 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.