Citation Nr: A21020072 Decision Date: 12/16/21 Archive Date: 12/15/21 DOCKET NO. 200515-84224 DATE: December 16, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea, as secondary to post-traumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1976 to September 1996. In the May 15, 2020 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ), May 5, 2020, decision on appeal. 38 C.F.R. § 20.301. Service connection for obstructive sleep apnea claimed as secondary to service-connected PTSD The issue of entitlement to sleep apnea is remanded to correct a duty to assist error that occurred prior to the May 2020 rating decision on appeal. The AOJ obtained a March 2020 medical opinion prior to the May 2020 rating decision on appeal. However, this medical opinion does not provide an adequate rationale regarding whether the Veteran's sleep apnea is aggravated by his service-connected PTSD. The Veteran contends his obstructive sleep apnea is secondary to his service-connected PTSD. The May 2020 rating decision made the favorable finding that the Veteran has a current disability of obstructive sleep apnea. The Veteran is service connected for PTSD at 70 percent, effective January 30, 2017. The Veteran was afforded a VA examination on March 31, 2020. There the examiner opined the Veteran's sleep apnea was less likely than not proximately due to or the result of the Veteran's service-connected PTSD. The examiner stated that while the Veteran has a confirmed diagnosis of sleep apnea, there is no medical evidence or studies to directly connect sleep apnea with PTSD. He explained: Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the soft palate, the uvula - a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue. Anyone can develop sleep apnea. However, certain factors put you at increased risk... He listed risk factors for obstructive sleep apnea and further explained, "PTSD is not the accepted cause of sleep apnea, nor is it a common risk factor." He finally opined the Veteran's sleep apnea "is not related to/caused by/aggravated by his in service PTSD." While this opinion addresses causation clearly, the examiner did not provide a separate finding and rationale for aggravation. Examiners must provide separate findings and rationales for both the question of causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Further, the findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b). See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Finally, an opinion that there is "no etiological relationship" may be insufficient to address the question of aggravation. See Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). The failure to obtain an adequate aggravation opinion was a pre-decisional duty to assist error. A remand is required to afford the Veteran an aggravation opinion. The Veteran's former representative raised a theory of direct service connection for the first time in a September 2020 submission. As it was received after the May 2020 rating decision on appeal, the fact that the AOJ did not obtain a direct service connection opinion cannot be a pre-decisional duty to assist error. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the March 2020 examiner if possible (if unavailable, send to an appropriate clinician). Please state whether the Veteran's sleep apnea is at least as likely as not aggravated beyond its natural progression by the service-connected PTSD. Please explain the medical reasoning supporting the opinion, with the knowledge that merely stating, "not due to," "not caused by," "not related to," or "no etiological relationship" are likely insufficient to address the question of aggravation. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Brewer, 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.