Citation Nr: 21009996 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 17-39 279 DATE: February 23, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or other specified trauma and stressor-related disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1986 to December 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected PTSD and/or other specified trauma and stressor-related disorder, is remanded. Although the Board regrets the additional delay, remand is required for an adequate VA opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board is also obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The Veteran was provided with a VA examination in October 2020 to determine the etiology of his sleep apnea. The examiner first stated that the Veteran’s sleep apnea was less likely than not related to active service as there was no documented evidence of sleep apnea or symptoms in the STRs. The examiner then stated that the Veteran’s sleep apnea was less likely than not caused by the Veteran’s service-connected PTSD. The examiner explained that sleep apnea is a condition caused by a narrowing of the upper airways and PTSD did not cause this structural pathology. In a November 2020 addendum, the examiner then determined that the Veteran’s sleep apnea was less likely than not aggravated by the Veteran’s PTSD. The examiner noted that of the Veteran’s evaluated for PTSD, 69.2 percent of them were at high risk for sleep apnea. The examiner also noted that the biggest risk factor for sleep apnea is excessive weight, but that research was still required to determine why PTSD was linked with sleep apnea. The examiner also found that research showed that the incidence of sleep apnea climbed for those with PTSD. The examiner then reiterated that the Veteran’s PTSD had not aggravated his sleep apnea. He noted that the Veteran’s PTSD had not progressed, that the Veteran already had severe sleep apnea, and that the link between PTSD and sleep apnea was not certain. The Board finds these examinations to be inadequate as the examiner’s opinion regarding aggravation is confusing. The examiner begins his rationale by providing evidence of a positive relationship between PTSD and a sleep apnea condition. The examiner then ultimately denies nexus despite the evidence he provided of a correlation between the two conditions without providing adequate rationale for his negative opinion. It is unclear how the fact that the Veteran’s PTSD had not progressed, and that the Veteran’s sleep apnea was severe, related to the examiner’s negative nexus opinion. The examiner simply stated these facts without providing an explanation as to how they support his opinion. The examiner then seemed to contradict the evidence he provided of a positive relationship between PTSD and sleep apnea by stating that the evidence of a relationship was not conclusive. The Board also finds that the examiner failed to adhere to the remand directives from the prior Board decision. In the October 2020 Board remand, the examiner was instructed to address the medical treatise evidence received on September 1, 2019: "Perspectives: The Importance of Recognizing an Association Between Obstructive Sleep Apnea and Post-Traumatic Stress Disorder"; and "Posttraumatic Stress Disorder and Sleep". The examiner was also directed to address the September 2019 opinion from the Veteran’s private physician which included a positive nexus opinion. The examiner did not address either piece of evidence in providing his opinion. As such, remand is required for an opinion which adequately addresses the evidence of record as directed by the Board. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran’s sleep apnea. The entire claims file must be made available to and be reviewed by the examiner. An explanation for all opinions expressed must be provided. If an examination is deemed warranted, one must be provided. The relevant Disability Benefits Questionnaire must be utilized. First, the examiner must opine whether the Veteran’s sleep apnea is at least as likely as not related to an in-service injury, event, or disease. Second, the examiner must opine as to whether the Veteran’s sleep apnea is at least as likely as not (1) proximately due to service-connected PTSD and/or other specified trauma and stressor-related disorder, or (2) aggravated by service-connected PTSD and/or other specified trauma and stressor-related disorder. The examiner is asked to comment on the Veteran’s risk factors for developing sleep apnea, both during and after his service. The examiner must address the medical treatise evidence received on September 1, 2019: "Perspectives: The Importance of Recognizing an Association Between Obstructive Sleep Apnea and Post-Traumatic Stress Disorder"; and "Posttraumatic Stress Disorder and Sleep". The examiner must address the September 2019 private opinion from Dr. Guthrie, to include the treatise evidence discussed within. 2. Request the curriculum vitae of the examiner who provides this addendum opinion, or relevant information regarding the examiner’s medical background and expertise. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. Provide notice to the Veteran and his representative of the relevant information or the inability to obtain such information. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ashley Ki 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.