Citation Nr: 21068727 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 16-09 590 DATE: November 12, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected major depressive disorder (MDD) with generalized anxiety disorder (GAD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1984 to March 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2019, the Veteran presented testimony before the undersigned Veterans Law Judge, and a copy of the transcript is of record. This matter was previously remanded in February 2020 and June 2021 for further development. The matter returns for appellate consideration. Entitlement to service connection for OSA, to include as secondary to service connected MDD with GAD, is remanded. The Veteran contends that his OSA is directly related to his active service in the Air Force, to include exposure to chemical solvents. However, the most recent medical evidence suggests a possible alternative theory of secondary service connection to MDD with GAD. Pursuant to the June 2021 Board remand, a June 2021 VA addendum opinion was obtained to address the nature and etiology of the Veteran's OSA. The examiner provided an extensive negative nexus opinion. First, the examiner indicated that service records are silent for any diagnosis or suspicions for OSA; and that while complaints for sleeping/fatigue were noted in the June 1985, April 1987, April 1988, and March 1990 health questionnaires, OSA was not diagnosed until December 2014. Second, and more notably, the examiner recognized the Veteran has been diagnosed with MDD which is well known to cause difficulty sleeping and fatigue. In noting the 1989 service records documenting complaints for difficulty falling asleep, lack of interest in life, lack of motivation, low energy, and dysphoric mood characterized as symptoms of "insomnia" and not OSA, the examiner reported that difficulty falling asleep is not a hallmark of OSA. Third, the examiner confirmed review of medical literature that attribute OSA to other factors such as age, male gender, history of smoking, and positive familial history, or other anatomical abnormalities of the upper airway including jaw conditions and nasal septal issues producing "airway crowding" to name a few. Fourth, the examiner concluded that there is no known association between chemical solvents and development of OSA over time but noted service records in June 1985, April 1986, and September 1986 evidencing obstruction of nasal passages and shortness of breath due to occupational exposure would dissipate after exposure ceased. Additionally, the examiner acknowledged the Veteran's statements regarding early onset of his sleep difficulty far prior to his 2014 diagnosis of OSA but concluded that his complaints in service characterized by difficulty initiating and maintaining sleep were due to insomnia caused by depression and stress. Furthermore, the examiner discredited medical literature submitted by the Veteran in support of a causal relationship between chemical solvents and OSA. Lastly, the examiner concluded that the Veteran's disordered sleep during service mimicked insomnia and in turn related more to his depression and psychosocial factors, such as stress, long periods of lying awake, and difficulty falling asleep. In addition, the examiner noted the Veteran began to develop symptoms of another sleep problem, i.e., true OSA around 2009, at which time he was older, had a history of smoking, and other anatomical airway issues which caught up to him and resulted in typical airway collapse and obstruction in OSA; to this point the examiner stated there was nothing to suggest that conceded exposure to jet fuel would cause OSA to occur many years following occupational exposure. The Board finds the June 2021 opinion is inadequate. While the examiner provided a very detailed analysis and rationale in support of the conclusion, the theory of secondary service connection was raised and an opinion addressing whether the Veteran's MDD proximately caused or aggravated his OSA is warranted. For example, the examiner noted that symptoms of difficulty initiating and maintaining sleep were symptoms of insomnia due to stress and depression. However, regarding complaints of shortness of breath and obstruction of nasal passages (noted by the October 2020 VA examiner to be a characterization of OSA) the examiner only concluded that chemical solvents causing such symptoms would not result in long term effects of OSA over time once exposure ceased. The examiner did however indicate MDD is known to cause difficulty sleeping and fatigue and that the Veteran later developed another sleep problem, i.e., true OSA, over time. As such, an addendum opinion addressing secondary service connection is warranted. The matter is REMANDED for the following actions: 1. Obtain an addendum opinion from the June 2021 VA examiner or another qualified clinician. The clinician providing the opinion must be provided access to the electronic claims file and indicate review of the file in the examination report. If examination of the Veteran is necessary, such should be arranged. The examiner is asked to determine whether the Veteran's OSA is at least as likely as not (50 percent probability or more) proximately caused by or aggravated by the service-connected MDD with GAD. The clinician must provide separate findings and rationales relating to causation and aggravation. Aggravation under 38 C.F.R. § 3.310 (b) does not require that there be "permanent" worsening of the nonservice connected disability. The examiner should discuss whether there are any overlapping symptoms of insomnia and OSA, and whether those symptoms were aggravated by MDD over time. The examiner should also discuss any known medical literature supporting a causal relationship between MDD and other sleep disorders such as OSA. (Continued on the next page) The examiner must provide a rationale in support of all opinions provided. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. 2. Then, readjudicate the Veteran's claim on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Asfaw, 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.