Citation Nr: 21069311 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 14-01 066 DATE: November 18, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected left knee disability, hypertension, and/or posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active service from June 1988 to November 1996. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in April 2016 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In April 2016, January 2018, March 2020 and July 2021, the Board remanded this claim for additional development. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran seeks entitlement to service connection for sleep apnea, and has asserted several theories of entitlement, to include both direct and secondary. The Veteran asserts he began experiencing loud snoring and apneic episodes during service. In support of his claim, the Veteran provided a buddy statement from a fellow servicemember who indicated that he had to wake up the Veteran "several times during the night because of his snoring and seeming like he wasn't breathing." The VA medical opinion obtained in April 2018 explained that 40 to 60 percent of obstructive apnea cases are attributable to obesity and that the Veteran has "been obese most of his life." Similarly, the May 2020 VA opinion states that the Veteran has long-standing obesity and noted that service treatment records reported a body fat percentage of 20 percent in September of 1994, with a notation that maximum allowed for males at that time was 26 percent. The examiner stated that the Veteran's body mass index (BMI) during service, at age 25, two years prior to discharge from service, was 27.7, based on a recorded height of 68 inches and a weight of 182 pounds, which is classified as "overweight" based on standard BMI charts. The examiner noted that this evaluation appeared to be "disciplinary" for the issue of weight control. The examiner noted that snoring, observed apneas, and sleepiness/fatigue are supportive criteria which are used to justify a concern for having sleep apnea and are used to justify ordering a sleep study, however, the examiner opined that the Veteran's sleep apnea was less likely than not due to service as the Veteran was not diagnosed until his sleep study was performed in 2010. Despite multiple remands directing the RO to obtain VA medical opinions, to date, an adequate VA medical opinion regarding direct service connection has not yet been obtained. Although the examiners have acknowledged the Veteran's lay statements regarding in-service symptoms, the examiners have continued to opine that the Veteran's sleep apnea is less likely than not due to service based upon a rationale that the Veteran was not medically diagnosed with sleep apnea until many years after service. Furthermore, although VA examiners have indicated the Veteran's sleep apnea is related to obesity and that he has long-standing obesity and difficulty with weight control, including during service, the opinions provided continue to emphasize that a diagnosis of sleep apnea was not made until many years after service and that sleep apnea is only diagnosed with a sleep study. The Board is aware that the medical evidence indicates the Veteran was not medically diagnosed with sleep apnea until approximately 2010. The question here is whether the Veteran's sleep apnea at least as likely as not had an onset during service given his credibly reported in-service symptoms of loud snoring, apneic episodes, and fatigue, as well as his documented status as overweight in service. On remand, an addendum opinion should be obtained. Additionally, while this case is in remand status, the Veteran and/or his representative is free to obtain a medical opinion to substantiate the claim. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Obtain an addendum VA opinion for the Veteran's obstructive sleep apnea. After a review of the claims file, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that, although not medically diagnosed until 2010, the Veteran's sleep apnea had an onset during service given his credible reports of in-service snoring, apneic episodes, fatigue, documented difficulty with weight control and "overweight" BMI during service. *In so opining, the examiner is hereby notified that the Board is cognizant that a medical diagnosis of sleep apnea was not made until post service in 2010; however, the Veteran asserts his sleep apnea had an onset during service in the form of in-service snoring, apneic episodes, and fatigue and medical evidence indicates he had difficulty controlling his weight during service and was classified as "overweight" during service. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Andersen, 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.