Citation Nr: 21069607 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 12-17 372 DATE: November 19, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1975 to April 1978 and from January 1982 to June 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board last remanded the issue on appeal in June 2021. However, the Board finds that remand is necessary for additional development as discussed below. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes on the Veteran's June 2012 substantive appeal, he requested a hearing before the Board. However, in an October 2014 statement, the Veteran, through his representative, requested to withdraw his hearing request. Therefore, the Veteran's hearing request is withdrawn, and the Board will proceed with adjudication of the issues. See 38 C.F.R. § 20.704(e). Entitlement to service connection for OSA, to include as secondary to service-connected disabilities, is remanded. The Veteran seeks service connection for OSA. Specifically, the Veteran contends that his OSA originated during his military service and has worsened over the years. See May 2011 statement in support of claim. The Veteran's wife contends that the Veteran's sleep disorder dates back to the time he was in service when he was diagnosed with rheumatoid arthritis in the 1990's and the Veteran's sleep was very restless and filled with extreme snoring. See March 2011 buddy statement. The Veteran also contends that his OSA is due to pain which prevented him from falling asleep associated with his service-connected disabilities. See June 2010 statement in support of claim; May 2021 and October 2021 appellate briefs. The Veteran was diagnosed with OSA in July 2006. See July 2006 private sleep study. The Veteran is currently service connected for bilateral shoulder and knee degenerative joint disease, bilateral ankle strain, bilateral hearing loss, and tinnitus. The Board finds that remand is necessary for further development in order to comply with the Board's prior remand directives. Stegall, 11 Vet. App. at 271. The Veteran has been afforded multiple VA examinations and medical opinions regarding the issue of entitlement to service connection for OSA, to include as secondary to service-connected disabilities. However, the Board previously determined VA medical opinions provided in July 2019 and February 2020 were inadequate for decision making purposes. Most recently, in its June 2021 remand, the Board found the March 2021 VA addendum medical opinion failed to consider potentially favorable evidence provided by the Veteran. Specifically, the Veteran's representative referenced a 2015 research study from the Journal of Physical Therapy Science that discusses a relationship between chronic widespread musculoskeletal pain and OSA. As such, the Board remanded the issue to obtain an addendum medical opinion. The Veteran was afforded an addendum medical opinion in July 2021. The VA examiner opined that it was less likely than not that the Veteran's OSA was incurred in or caused by an in-service event, injury, or illness. See July 2021 VA medical opinion. As rationale, the VA examiner considered the Veteran's lay statements and wife's lay statements; however, noted neither he nor his wife are capable of diagnosing the symptoms nor of establishing an etiological relationship for the symptoms. Id. The VA examiner noted there was no objective evidence to support an etiology for the Veteran's OSA to his service. Id. The VA examiner considered the research article referenced by the Veteran's representative and noted there is a slight statistical association (barely greater than chance) between arthralgia or other musculoskeletal pain and sleep disturbance has been found; however, the VA examiner noted there is no causal relationship for OSA due to the chronic joint pain the Veteran experienced during service. Id. With respect to secondary service connection, the July 2021 VA examiner opined that it was less likely than not that the Veteran's OSA was proximately due to or the result of the Veteran's service-connected disabilities, including bilateral shoulder and knee degenerative joint disease, bilateral ankle strain, bilateral hearing loss, and tinnitus. See July 2021 VA medical opinions. However, the VA examiner did not provide an opinion as to whether the Veteran's OSA was aggravated, or worsened, by any of his service-connected disabilities. As such, an addendum medical opinion, to include a clear aggravation opinion should be obtained upon remand. See 38 C.F.R. § 20.802; see also El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013); Atencio v. O'Rourke, 30 Vet. App. 74, 90-91 (2018). The matters are REMANDED for the following action: 1. Forward the record and a copy of this Remand to the examiner who provided the July 2021 medical opinion, or, if that examiner is unavailable, to another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that a new examination is necessary to provide the requested opinion, such examination should be scheduled. The examiner should address whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's OSA is aggravated (i.e., worsened) by the Veteran's service-connected disabilities, including bilateral shoulder and bilateral knee degenerative joint disease, bilateral ankle strain, bilateral hearing loss, and tinnitus. The examiner must consider and address the Veteran and his spouse's lay statements. The examiner must consider and address the 2015 research study from the Journal of Physical Therapy Science provided by the Veteran's representative, as well as the July 2019 VA examiner's notation that ongoing studies show that pain syndromes can cause OSA. A complete rationale for each opinion expressed must be provided. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Carlin 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.