Citation Nr: 21074072 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 16-29 514 DATE: December 14, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1982 to September 1992, and from November 2004 to August 2006, including service in Iraq from January to December 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). It was previously remanded in March 2019. Entitlement to service connection for obstructive sleep apnea is remanded. As a preliminary matter, the Board notes that since the issuance of the Supplemental Statement of the Case (SSOC) in July 2020, updated VA medical center (VAMC) treatment records have been associated with the claims file. As remand is necessary for the additional reasons as explained below, remand will allow the RO to review such records. The matter initially appeared before the Board in March 2019 at which time the issue was remanded for further development. The Board noted that a November 2013 VA sleep study was not of record and that a medical opinion was needed to resolve the discrepancies in the medical evidence and address whether the Veteran's current obstructive sleep apnea (OSA) manifested during active-duty service or whether his service-connected hypertension caused or aggravated his sleep apnea. The Board further noted that in an August 2014 VA medical center (VAMC) note, the Veteran's primary care provider indicated that the Veteran's sleep apnea was not treated or diagnosed for years despite complaints documented back to 2006 and that he had sleep apnea since at least 2006 because his insomnia complaints were well documented and many of his well-documented complaints improved with the use of CPAP. The Board further noted that the Veteran injured his right elbow and shoulder in service during deployment and discontinued use of Elavil for help with sleep due to side effects. VA sleep apnea opinions were subsequently obtained in December 2019. In regard to whether the Veteran's sleep apnea was directly related to service, or proximately due to services related conditions, including joint pains or insomnia, the examiner opined that the Veteran's current OSA was less likely than not incurred from active service. The examiner rationalized that based on medical records containing clinical notes in February 2006 of right shoulder pain affecting sleep, reports of shoulder pain affect sleep on Elavil, clinical note in January 2006 reporting trouble sleeping due to pain, MEB in June 2006 reporting trouble sleeping due to right elbow pain, post deployment health assessment in January 2005 and December 2005 denying feeling tired after sleeping, clinical notes in 2007 reporting sleep issues due to psychological issues and current medical literature, such evidence and medical literature does not support joint pain or hypertension as cause of sleep apnea which suggest current OSA is not due to active service nor is it related to his secondary insomnia due to joint pains. The examiner further opined that the Veteran's current OSA is less likely than not incurred from hypertension. The examiner rationalized that based on 2013 medical records clinical note reporting OSA and current medical literature, the evidence and medical literature does not support joint pain or hypertension as cause of sleep apnea which suggest current OSA is not due to hypertension. In regard to whether the Veteran's sleep apnea was aggravated by service-related conditions, the examiner opined that since sleep apnea was diagnosed in 2013 with prescribed CPAP treatment and the Veteran was still currently treated with CPAP which suggests current OSA is not aggravated beyond baseline from 2013 from service-related conditions. Here, the Board finds the above opinions are all inadequate. First, the examiner found that the evidence of record and medical literature does not support that service, or the noted service-related conditions caused or aggravated the Veteran's sleep apnea. However, the examiner did not cite to such medical literature for the Board's nor the Veteran's review. Second, the examiner did not actually provide a reasoned medical explanation. The rationale simply recites medical records but does not explain what those records mean in light of the conclusion reached; the opinions are essentially data and conclusions. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Third, the opinions fail to address the August 2014 VAMC treatment record noting the condition was likely present since 2006. Id. Hence, the Board finds a remand is warranted to obtain adequate opinions. The matter is REMANDED for the following action: Forward the Veteran's electronic claims file and a complete copy of the REMAND to an appropriate clinician with knowledge and experience in sleep medicine. Following a review of the claims file, including the August 2014 opinion by the Veteran's primary care physician, the March and April 2016 and December 2019 VA medical opinions, the reviewing examiner should provide an opinion as to: (1) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's obstructive sleep apnea, which was diagnosed in November 2013, had its onset during service or is otherwise medically related to his active-duty service; or (2) Whether his obstructive sleep apnea was proximately due to OR has been aggravated by his service-connected disabilities, including hypertension or as a side effect of medication from his joint disabilities. Please specifically discuss the medical evidence showing reports of difficulty sleeping in 2006, when the Veteran was still on active duty, and the August 2014 VAMC treatment record noting the condition was likely present since 2006. A complete rationale must be given for all findings. If the examiner refers to medical literature, please clarify exactly what literature is being referred to, and what that literature states. If the requested opinions cannot be rendered without resorting to speculation, the examiner must explain why providing such estimates is not possible. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Alli, Associate 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.