Citation Nr: 21070619 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 20-09 104 DATE: November 24, 2021 REMANDED Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from May 1966 to March 1969, including service in Vietnam. 1. Entitlement to service connection for sleep apnea is remanded. VA treatment records indicate that the Veteran was diagnosed with moderate obstructive sleep apnea hypopnea syndrome in February 2015. In his November 2018 claim for disability benefits and February 2019 notice of disagreement, the Veteran asserted that the sleep apnea was due to his service-connected posttraumatic stress disorder (PTSD). In January 2019, a VA medical opinion was obtained in which a physician assistant opined that the Veteran's sleep apnea was less likely than not proximately due to or the result of the service-connected PTSD. Sleep apnea was noted to have been linked to PTSD, but the mechanism for the underlying relationship between sleep apnea and PTSD in military veterans remained unclear and there was no evidence-based medical literature to support the contention that obstructive sleep apnea is caused by PTSD. Causes of sleep apnea include muscular changes or physical obstructions causing restriction of airflow. In February 2020, a VA physician reviewed the claims file and opined that the claimed sleep apnea was less likely than not proximately due to or the result of the service-connected PTSD. The examiner noted that he reviewed and appreciated the literature provided by the Veteran, which discussed associations/correlations. Causation between obstructive sleep apnea and PTSD was not established, and a more recent study evaluating Australian veterans with obstructive sleep apnea and PTSD found no nexus of causation between the two conditions. The examiner also opined that the claimed sleep apnea was less likely than not proximately due to or the result of the service-connected diabetes mellitus. The rationale was that although there was some increased risk associated with diabetes mellitus, it was not considered a major risk factor. Moreover, elevated BMI is a leading risk factor of obstructive sleep apnea, and at the time of diagnosis, the Veteran had a markedly elevated BMI. The Board finds that these opinions are inadequate to adjudicate the issue of service connection for sleep apnea, as they do not address the issue of whether the sleep apnea was aggravated by the service-connected PTSD and/or diabetes mellitus. See Allen v. Brown, 7 Vet. App. 439 (1995) (holding that service connection can be granted for a disability that is aggravated by a service-connected disability and that compensation can be paid for any additional impairment resulting from the service-connected disorder). Furthermore, the Veteran's representative raised additional theories of entitlement in an October 2021 Written Brief Presentation, including that the sleep apnea was due to or aggravated by the service-connected diabetic neuropathy, and/or that the PTSD symptoms caused behavioral effects including physical inactivity and weight gain, which caused the sleep apnea. The Board therefore finds that remand for a medical opinion addendum is necessary. 38 U.S.C. § 5103A(d). The matter is REMANDED for the following action: Contact the VA examiner who provided the February 2020 VA medical opinions (or if he or she is no longer available, a suitable replacement) on the etiology of the obstructive sleep apnea and ask the examiner to review the record and prepare an addendum to the medical opinions. The entire claims file, including a copy of this REMAND, must be reviewed by the examiner. The examiner should provide an opinion on whether it is at least as likely as not that the obstructive sleep apnea is causally related to and/or increased in severity by the service-connected PTSD, diabetes mellitus, and or diabetic neuropathy. The examiner should specifically consider and discuss the Veteran's assertions that his PTSD symptoms caused behavioral effects including physical inactivity and weight gain, which caused the sleep apnea. If the examiner finds that the sleep apnea is aggravated by the PTSD, diabetes mellitus, and/or diabetic neuropathy, the examiner should report the degree of severity of the disability before the onset of aggravation and report the current level of severity of the disability. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Nelson 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.