Citation Nr: 21007844 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 16-51 619 DATE: February 10, 2021 REMANDED 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected traumatic brain injury (TBI), is remanded. 2. Entitlement to service connection for idiopathic hypersomnia is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1980 to September 2000. These matters are before the Board of Veterans’ Appeals (Board) on appeal from October 2014 and August 2016 rating decisions. In March 2019, a Travel Board hearing was held before the undersigned; a transcript is in the record. In July 2019, the Board remanded these matters for additional development. [The matter of service connection for a left elbow disability was also remanded. A July 2020 rating decision granted service connection for a left elbow disability, resolving that matter.] The Board finds that there has not been substantial compliance with previous remand directives, and that corrective action is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected TBI. The July 2019 Board remand sought a medical opinion (with rationale) addressing whether the Veteran’s sleep apnea was caused or aggravated by his service-connected TBI. The examiner was specifically asked to review/address medical literature submitted by the Veteran’s representative in March 2019. On September 2019 medical examination and opinion received in response, the provider explained “obstructive sleep apnea occurs due to repetitive collapse of the upper airway. Risk factors of obstructive sleep apnea include older age, male gender, obesity, comorbidities such as hypertension, diabetes, cardiovascular diseases, craniofacial abnormalities, and upper airway soft tissue abnormalities.” The examiner opined that sleep apnea was not caused by the Veteran’s TBI. The examiner did not provide a full opinion addressing whether the Veteran’s sleep apnea was aggravated by his service-connected TBI. Furthermore, the examiner did not indicate that the medical literature submitted by the Veteran’s representative in March 2019 was reviewed or discuss it (as the July 2019 Board remand requested). Accordingly, a new medical opinion that adequately addresses (1) the medical textual evidence submitted. and (2) whether the Veteran’s sleep apnea was aggravated by his service-connected TBI is necessary. 2. Entitlement to service connection for idiopathic hypersomnia. The July 2019 Board remand sought a medical opinion (with rationale) addressing whether the Veteran’s idiopathic hypersomnia was caused or aggravated by his service-connected TBI. The Board noted that whether the Veteran’s idiopathic hypersomnia is etiologically related to his sleep apnea was raised by the record. On September 2019 medical examination and opinion received in response, the provider stated, “given the history of MVA, it is likely that his TBI is a contributing factor to his chronic sleepiness.” See September 2019 Medical Opinion pg. 7. In a June 2020 medical opinion, the consulting clinician opined that it was less likely than not that the Veteran’s idiopathic hypersomnia is related to his service-connected TBI. The clinician stated the origin of the Veteran’s idiopathic hypersomnia was unknown, with no documented relationship to his service-connected TBI. However, such opinion seems to disregard the prior opinions indicating that the Veteran’s TBI may be a contributing factor to chronic sleepiness, as well as the prior opinion that the Veteran’s idiopathic hypersomnia may be related to his sleep apnea. See July 2017 Medical Opinion. Accordingly, development for a medical opinion which reconciles these conflicting medical opinions is necessary. The matters are REMANDED for the following: Arrange for the Veteran’s record to be forwarded to an appropriate clinician for review and a medical advisory opinion regarding the likely etiology of his (i) sleep apnea and (ii) idiopathic hypersomnia. The Veteran’s record (to include the medical literature received in March 2019) must be reviewed by the examiner. On review of the record, the clinician should: (a.) Identify the likely etiology for the Veteran’s (i) sleep apnea and (ii) idiopathic hypersomnia. Specifically, is it at least as likely as not (a 50% or better probability) that they were caused or aggravated by the Veteran’s service-connected TBI? [the opinion must address aggravation.] (b.) If the (i) sleep apnea and/or (ii) idiopathic hypersomnia are determined to not have been caused or aggravated by the Veteran’s service-connected TBI, identify the etiology for the disabilities that is considered to be more likely and explain why that is so. (c.) If the Veteran’s sleep apnea is found to be caused or aggravated by the Veteran’s TBI (and idiopathic hypersomnia is not found to have been caused or aggravated by the TBI), opine further whether it is at least as likely as not (a 50% or better probability) that the Veteran’s idiopathic hypersomnia was caused or aggravated by his sleep apnea? All opinions must include rationale that cites to supporting factual data and medical principles, discusses the applicability of the medical literature submitted by the Veteran, and reconciles the June 2020 medical advisory opinion with the cited apparently conflicting opinions that were already in the record. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Staskowski, 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.