Citation Nr: 21069930 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 17-46 802 DATE: November 22, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to service-connected posttraumatic stress disorder with cognitive impairment, depression, and sleep disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to January 1969. He was in receipt of a Purple Heart and Vietnam Campaign Medal, among others. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran died in January 2020. See Death Certificate (January 2020). The appellant is the Veteran's surviving spouse. See Correspondence (April 2020). In November 2020, the appellant testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. Entitlement to service connection for OSA as secondary to service-connected PTSD is remanded. The appellant contends that the Veteran's OSA was due to his service-connected PTSD. See Hearing Transcript (November 2020). The appellant asserts that the relationship between the two disabilities is that OSA results from the nightmares, insomnia, depression, and self-medicating due to PTSD. See Hearing Transcript (November 2020). The Board finds that remand is warranted for addendum opinions. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In a secondary service connection claim, there must be evidence of a disability that is "proximately due to or the result of" a service-connected disease. 38 C.F.R. § 3.310(a). This describes a causal relationship. Walsh v. Wilkie, 32 Vet. App. 300, 305 (2020). "A mutual relationship or some degree of correspondence that is not based on causation or aggravation is not sufficient to meet the requirements of § 3.310." Harvey v. Shulkin, 30 Vet. App. 10, 20-21 (2018). Here, a prior Board decision found a 2017 VA medical opinion inadequate for purposes of adjudicating the claim on appeal. See BVA Decision (March 2021). The Board noted that the examiner relied on medical literature but did not cite or reference that literature, or consider facts specific to the Veteran when addressing the literature. See BVA Decision (March 2021). Additionally, the opinion did not address secondary service connection based on aggravation. See BVA Decision (March 2021). The Board also found a 2019 private opinion from Dr. DB insufficient upon which to adjudicate the issue, noting that it relied on association, rather than causation, between the service-connected PTSD and the sleep apnea. See BVA Decision (March 2021). The Board also noted that Dr. DB's opinion also relied on medical literature, but did not discuss any facts specific to the Veteran in relationship to that literature. See BVA Decision (March 2021). Thus, remand for an addendum opinion was directed. In the remand directives, the Board requested that the examiner provide the necessary opinions, and expressly address the March 2019 private medical opinion. See BVA Decision (March 2021). June 2021 VA addendum opinions were obtained. See C&P Exam (June 2021). The examiner opined that the sleep apnea was not proximately due to or aggravated by service-connected PTSD. The examiner based this opinion on the presence of the Veteran's risk factors, that although current medical studies indicate an increased risk of OSA in individuals with PTSD, a causal link has not been established, and that medical literature does not indicate that OSA exacerbates PTSD. See C&P Exam (June 2021); C&P Exam (June 2021). First, the Board finds that the 2021 VA addendum opinions do not comply with the prior remand as they do not address Dr. DB's March 2019 medical opinion. Second, the aggravation opinion addresses an incorrect relationship: whether OSA exacerbates PTSD rather than whether PTSD exacerbates the OSA. Third, again, the examiner did not address any facts specific to the Veteran in relationship to the cited medical literature. In a March 2021 submission, Dr. DB asserted that their 2019 private opinion met the criteria of "at least as likely as not" that the OSA is "proximately due to" PTSD and service connection was thus supported. See Medical Treatment Record Non-Government Facility (March 2021). In a July 2021 submission, Dr. DB stated that the newly provided 2021 VA opinions were inadequate as the opinions appeared to require a causative etiology, rather than a proximity to another condition. See Medical Treatment Record Non-Government Facility (November 2021). The examiner noted that he and the VA examiner have cited the same studies in support of their opinions. See Medical Treatment Record Non-Government Facility (November 2021). Although Dr. DB attempted to provide a supplemental supporting rationale for the 2019 opinion, Dr. DB focused on his finding of proximity and asserted that causation was not required. As noted above, this is incorrect and the opinion remains inadequate to support service connection. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the sleep apnea from an appropriate VA examiner. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with the diagnosed sleep apnea. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). Whether the Veteran's sleep apnea is at least as likely as not (1) proximately due to service-connected PTSD, or (2) aggravated beyond its natural progression by service-connected PTSD. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address the following: a) March 2019 private opinion and the March 2021 and July 2021 supporting explanations; b) medical literature as previously cited or as relevant; and c) the prior VA opinions dated in 2017 and 2021. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 2. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.