Citation Nr: 21008062 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 12-17 372 DATE: February 11, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as due to service-connected disabilities, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from March 1975 to April 1978 and from January 1982 to June 1992. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a February 2011 Department of Veterans Affairs (VA) rating decision. In September 2016, March 2018, and February 2020, this matter was remanded for additional development. The Board is aware this matter was remanded three times before (and regrets the delay in final adjudication inherent with yet another remand). However, the responses to the prior remands did not adequately comply with prior remand instructions, and corrective action remains necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The February 2020 Board remand found the July 2019 VA examination failed to comply with the March 2018 remand directives, noting the examiner failed to consider/discuss the May 2011 buddy statement (wherein the Veteran’s wife stated that his ability to sleep was affected by his rheumatoid arthritis diagnosed in the early 1990s) and that it was based on an inaccurate premise (that a pain syndrome was not documented in the file). The February 2020 Board remand sought a VA medical opinion regarding the etiology of the Veteran’s OSA, specifically, whether it is etiologically related to his service or his service-connected disabilities, to include bilateral shoulder/knee arthritis (previously rheumatoid arthritis). The examiner was to specifically consider and discuss the May 2011 buddy statement, the July 2019 VA examination report (indicating that ongoing studies show that pain syndromes can cause OSA), the Veteran’s service treatment records (STRs) from the 1990s showing treatment for a probable diagnosis of seronegative rheumatoid arthritis, and a February 1994 diagnosis of sero-negative rheumatoid arthritis. On February 2020 VA examination, the examiner provided negative opinions regarding whether the Veteran’s OSA is related to his service or to his service-connected left knee or left shoulder disabilities. The examiner opined that OSA is an entirely separate entity from the service-connected left knee and left shoulder disabilities and is unrelated to the service-connected disabilities. While the examiner stated the medical literature does not support a medical relationship between the two and explained that obesity is a major risk factor for OSA, the examiner did not discuss the July 2019 VA examiner’s notation that ongoing studies show that pain syndromes can cause OSA. Arthritis in multiple joints has been service-connected since 1993 (although the service-connected disability has been recharacterized over the years from sero-negative rheumatoid arthritis in the bilateral knees, shoulders, and ankles to degenerative joint disease in the bilateral knees and shoulders and bilateral ankle strains). Additionally, while the examiner noted the May 2011 buddy statement, it was in the context of the negative with respect to direct service connection opinion rather than whether the OSA was related to his then-characterized as rheumatoid arthritis service-connected disability, as alleged. The opinion is not responsive to the Board’s remand directives, and corrective action is necessary. See Stegall, 22 Vet. App. at 271. The matter is 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 OSA. [If an examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The consulting provider should: (a.) Identify the likely etiology for the Veteran’s OSA (diagnosed in 2006). Specifically, is it at least as likely as not (a 50% or greater probability) related directly to his service (as due to disease or injury, or by onset, therein)? (b.) If OSA is not directly related to service, opine further whether it at least as likely as not (a 50% or greater probability) was caused or aggravated by (increased in severity due to) the Veteran’s service-connected disabilities (including bilateral shoulder and bilateral knee arthritis (previously rheumatoid arthritis)? [The opinion must address aggravation.] (c.) If the service-connected disabilities did not cause, but aggravated, the OSA, specify, to the extent possible, the degree of disability that resulted from such aggravation. Include rationale with all opinions. Specifically consider and discuss: i. the May 2011 statement by the Veteran’s wife indicating that his rheumatoid arthritis affected his ability to sleep and that he snored, ii. the July 2019 VA examination report indicating that ongoing studies show that pain syndromes can cause OSA, and iii. the Veteran’s STRs from the 1990s showing treatment for a probable diagnosis of seronegative rheumatoid arthritis and February 1994 diagnosis of sero-negative rheumatoid arthritis. The rationale must include a discussion of the underlying medical principles specific to the facts of this case and not simply reference generic medical literature. If an opinion sought cannot be provided without resort to mere speculation, there must be a complete explanation why this is so. Indicate whether the inability to provide a more definitive opinion (without mere speculation) is the result of a need for additional information or that or due to limitations in the current state of medical knowledge. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Naumovich, 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.