Citation Nr: 21068802 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 15-35 916 DATE: November 12, 2021 REMANDED Entitlement to service connection for a sleep disability, to include as due to an undiagnosed multisymptom illness and/or secondary to posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating due to individual unemployability based on service-connected disabilities (TDIU), to include on an extraschedular basis is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1986 to June 1991. The Veteran testified before the undersigned Veterans Law Judge in February 2019. The Board of Veterans' Appeals (Board) remanded the matters for further development in March 2020 and July 2021. 1. Entitlement to service connection for a sleep disability is remanded. The claim was most recently remanded in order to obtain an addendum opinion to the December 2020 VA examination. The December 2020 VA examination provided contradictory dates of onset for the diagnosed sleep apnea; the negative nexus opinion did not address lay evidence of in-service sleep apnea symptoms; and the secondary nexus opinion did not address medications prescribed for PTSD. The Veteran was provided with a VA addendum opinion in August 2021. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue of entitlement to service connection for a sleep disorder, and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board directed the examiner to provide an opinion as to whether the Veteran's sleep disorder was related to active service, to include discussion of lay evidence of in-service symptoms. The August 2021 examiner did not address any lay evidence, and relied solely on the absence of evidence in the Veteran's service treatment records in finding the sleep apnea was not related to active duty. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). In providing the secondary nexus opinion, the examiner determined that PTSD and the medications did not cause sleep apnea, but Ambien and valium should not be used with sleep apnea. The Board did not limit the Veteran's opinion to Ambien and valium, but any medications prescribed due to PTSD. June 2021 VA treatment records show the Veteran had been diagnosed with psychotropic medications of trazodone, mirtazapine, venlafaxine, and VPA. The examiner provided a conclusory negative opinion as to whether PTSD aggravated sleep apnea, without an adequate rationale to explain their opinion. Additionally, the examiner did not address any diagnosed medications as to aggravation, when the examiner previously noted that Ambien and valium should not be used with sleep apnea without further explanation. Therefore, another remand is required. Stegall, supra. 2. Entitlement to a TDIU is remanded. The Board further finds that adjudication of the TDIU issue must be deferred, as it is inextricably intertwined with the issue being remanded herein. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: Forward the Veteran's claim file, to include this REMAND, to a qualified medical professional to obtain an addendum opinion regarding the nature and etiology of the Veteran's sleep disability. The examiner is asked to address the following: Explain the onset of the Veteran's sleep apnea, with specific attention provided to the December 2020 VA examination finding "the condition began during the service;" Provide an opinion as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that sleep apnea had its onset during or is otherwise related to any event or injury during active duty (lay evidence of in-service symptoms must be addressed); Provide an opinion as to whether it is at least as likely as not that sleep apnea was caused by PTSD and/or PTSD medications; Provide an opinion as to whether it is at least as likely as not that sleep apnea was aggravated beyond its natural progression by PTSD and/or PTSD medications, specifically including Ambien, valium, trazodone, mirtazapine, venlafaxine, and VPA. A complete rationale for all opinions expressed should be provided. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. N. Quarles, 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.