Citation Nr: 21010009 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 15-28 180 DATE: February 23, 2021 REMANDED Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from August 1980 to February 1985. Thereafter, he also had service in the United States Air Force Reserves, which includes a period of active duty service in August 2000. This matter initially came before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision issued by the Agency of Original Jurisdiction (AOJ). The matter was previously before the Board in March 2019. The appeal was remanded for a VA medical opinion as to the etiology of the Veteran’s sleep apnea. A medical opinion was associated with the file in January 2020. The Board finds that the January 2020 medical opinion is inadequate. Thus, further remand is required to ensure compliance with the March 2019 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for sleep apnea is remanded. The Veteran contends that his obstructive sleep apnea is etiologically linked to various bouts of strep throat, pharyngitis, and other upper respiratory illness the Veteran experienced during service in the 1980s. Alternatively, the Veteran argues that his sleep apnea was permanently aggravated during his active duty service in August 2000. Unfortunately, an additional remand is needed to obtain an addendum medical opinion as the January 2020 examiner failed to address the second contention. At the outset, the Board notes that the record contains no entrance examination for the August 2000 period of service. Therefore, sleep apnea was not noted at entry. However, the Veteran reports persistent symptoms of sleep apnea as early as the 1980s. Further, the record indicates the Veteran was diagnosed with severe sleep apnea only a few months after his deployment in August 2000. The Board cannot make a fully informed decision on the issue of service connection for sleep apnea because no VA examiner has opined whether the condition preexisted the Veteran’s August 2000 active duty service and/or was aggravated during that time. Accordingly, further remand is necessary. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his sleep apnea. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. 2. After completion of the development requested above, the AOJ should forward the entire claims file in electronic records to the January 2020 examiner for an addendum opinion on the nature and etiology of the Veteran’s sleep apnea. If the January 2020 examiner is unavailable, the entire claims file should be forwarded to a suitably qualified VA examiner. If additional examination is indicated, it should be scheduled in accordance with applicable procedures and all indicated studies should be performed. The claims file must be available to and be reviewed by the examiner, to include any newly obtained evidence as a result of the above ordered development. The examiner should provide an opinion regarding the nature and etiology of the Veteran’s sleep apnea, which addresses the Veteran’s service treatment records, post-service medical records, and lay statements. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 3. The examiner should provide an opinion as to the following inquiries: Does the Veteran have sleep apnea that clearly and unmistakably existed prior to his last period of active duty service in August 2000; If, and only if, the Veteran’s sleep apnea clearly and unmistakably existed prior to service, is there clear and unmistakable evidence that the Veteran’s sleep apnea, was NOT aggravated beyond its natural progression by an in-service injury, event, or illness; If the Veteran’s sleep apnea was aggravated by service or if the Veteran’s sleep apnea did not clearly and unmistakably exist prior to service, is it at least as likely as not (i.e., 50 percent probability or more) that the Veteran’s current sleep apnea is related to the aggravation in service or the claimed in service injury, event, or illness. The examiner should note aggravation indicates a worsening of the underlying condition as compared to an increase in symptoms. In this regard, the examiner must explicitly address the December 2000 private treatment records surrounding the Veteran’s sleep apnea diagnosis which note severe sleep apnea with anatomical obstruction at the level of both the nose and the tonsils/uvula/soft palate. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. All opinions must be accompanied by a clear rationale. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. After ensuring compliance with these objectives, the AOJ should readjudicate the claim. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Sherman 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.