Citation Nr: 21077355 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 17-40 058 DATE: December 29, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD) and lumbar strain, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2000 to December 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at an August 2021 Board hearing. A transcript of the hearing is of record. At the August 2021 hearing, the Veteran, through his representative, requested a 90-day extension to submit additional evidence. No additional evidence has been received, and the 90-day extension has expired. As such, the Board will proceed with adjudication of the pending claim. Entitlement to service connection for OSA, to include as secondary to service-connected PTSD and lumbar strain, is remanded. The Veteran seeks service connection for OSA. See June 2015 VA Form 21-526. The Veteran contends that his symptoms began during service. Specifically, the Veteran asserted that his wife told him he constantly stopped breathing in March 2008, and that he woke up several times gasping for air when in service. See June 2016 Notice of Disagreement (NOD); August 2021 Hearing Transcript. The Veteran also testified that he relates his OSA to his service-connected PTSD disorder and medication that he takes for his service-connected back disability. See August 2021 Hearing Transcript. The Board notes the Veteran has not been afforded a VA examination. The VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, (3) an indication that the disability or persistent recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In this case, the Board notes the Veteran testified that his symptoms of OSA began in service. See August 2021 Hearing Transcript. The Veteran testified that when he returned from deployment, his wife moved in with him and noticed that he was not breathing during his sleep. Id. He also testified that a friend in service witnessed him snoring and caught him not breathing in his sleep. Id. The Veteran underwent a VA examination in December 2008; however, the Veteran did not report any symptoms related to his OSA and OSA was not diagnosed at that time. See December 2008 VA examination. The Veteran's OSA diagnosis was confirmed in July 2016 following an at-home sleep study and the Veteran was issued a CPAP in August 2016. See July and August 2016 VA treatment records. Additionally, the Veteran testified that he was exposed to environmental hazards, such as dust, while deployed. See August 2021 Hearing Transcript. The Veteran's DD Form 214 demonstrates the Veteran completed deployments to Afghanistan and Iraq. In light of the above, the Board finds that the low threshold for provision of a VA examination described in McLendon has been met. Therefore, the Board finds that remand is necessary for a VA examination to determine the nature and etiology of the Veteran's diagnosed OSA, to include as due to environmental hazards while on deployment to Afghanistan and Iraq. The Board also notes that it is required to consider all theories of entitlement for service connection. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004); Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (explaining that the Board must consider all potential theories of entitlement raised by the evidence.). As noted, the Veteran testified that he relates his OSA to his service-connected PTSD and back disability, to include the medications that he takes to treat his conditions, including the medication that he takes for both conditions. See August 2021 Hearing Transcript. The Veteran testified that a study from the Sleep Foundation indicated a connection between PTSD and OSA, and that other studies relate OSA back to PTSD. Id. The Veteran testified that his PTSD medication, namely Trazodone, made his OSA even worse and he had to stop taking it. Id. At a psychological evaluation in September 2011, the Veteran reported difficulty sleeping. See September 2011 VA treatment records. In March 2015, the Veteran reported broken sleep and frequent awakenings. See March 2015 VA treatment records. As such, the Board finds that secondary service connection has been reasonably raised and remand is necessary to address entitlement to service connection for OSA as secondary to service-connected PTSD and lumbar strain. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's OSA. The record and a copy of this Remand must be made available to and reviewed by the examiner. (a.) The examiner must opine as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's OSA had its onset during service or is otherwise etiologically related to an in-service injury, event, or disease, to include exposure to environmental hazards while deployed to Afghanistan and Iraq. A complete rationale must be given for all opinions and conclusions expressed. The examiner must address and consider the Veteran's lay statements, including those provided at the August 2021 Board hearing, regarding the onset of his symptoms that he asserts began during service. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's OSA is proximately due to, or the result of, the Veteran's service-connected PTSD, to include any medications that he takes to treat these conditions. (c.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's OSA is aggravated (worsened) by the Veteran's service-connected PTSD, to include any medications that he takes to treat these conditions. (d.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's OSA is proximately due to, or the result of, the Veteran's service-connected lumbar strain, to include any medications that he takes to treat these conditions (e.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's OSA is aggravated (worsened) by the Veteran's service-connected PTSD lumbar strain, to include any medications that he takes to treat these conditions. A complete rationale should be given for all opinions and conclusions expressed. The examiner must consider and address the Veteran's lay statements, including those provided at the August 2021 Board hearing regarding studies that relate PTSD and OSA and that Trazodone made his OSA worse. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. 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.