Citation Nr: 21010486 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 17-63 362 DATE: February 25, 2021 REMANDED Entitlement to service connection for a breathing disorder, including as due to service in Southwest Asia, is remanded. Entitlement to service connection for obstructive sleep apnea, including as secondary to posttraumatic stress disorder (PTSD) and service in Southwest Asia, is remanded. Entitlement to service connection for hypertension, including as secondary to PTSD and service in Southwest Asia, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1980 to August 1983, June 2004 to April 2005, and from October 2011 to October 2012, including service in Southwest Asia. The Veteran had additional Reserve service. These matters come before the Board of Veterans’ Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing with the undersigned in November 2020. While the Statement of the Case styled the hypertension issue as one requiring new and material evidence, the Board finds that the issue is one of service connection and new and material evidence is not required to reopen the claim. See 38 C.F.R. §§ 3.156, 3.303. Service connection for hypertension was first denied in an August 2017 rating decision. It was again denied in a March 2018 rating decision. The Veteran filed her notice of disagreement (NOD) in May 2018 and subsequently perfected this appeal. As the NOD was timely to the August 2017 rating decision, that rating decision did not become final. 1. Service connection for a breathing disorder. The Veteran contends that she developed a breathing disorder, including sarcoidosis, due to her service in Southwest Asia and exposure to burn pits. In September 2017, the Veteran underwent a VA examination. The examiner stated that the Veteran’s condition – solitary nodule of lung, granulomatous disease with calcified lymph nodes – is an inherited disease, citing to medical literature. The examiner stated it is not caused by a toxic environmental exposure. Regarding the Veteran’s report that she had pneumonia prior to enlistment, the examiner noted that pneumonia is a common problem in chronic granulomatous disease. During a November 2018 VA examination, the Veteran was again diagnosed with a pulmonary nodule as well as granulomatous disease of the lung. The Veteran contends that she does not suffer from an inherited disease, and her October 1979 entrance examination is silent for any pre-existing condition. Upon remand, the examiner should address whether this condition clearly and unmistakably pre-existed her military service, and if so, whether her military service aggravated this condition. Further, the Veteran states that she possibly suffers from sarcoidosis. A June 2017 consultation note shows a medical history listing established pulmonary sarcoidosis, although diagnosis of sarcoidosis is not shown in the available records. An April 2018 assessment indicates that “[a] unifying diagnosis in this patient could be sarcoidosis causing PH or other etiology of PH. Other granulomatous disease could be possible.” The Veteran’s testimony suggests she has not been able to have testing done to confirm a sarcoidosis diagnosis because of the current COVID-19 pandemic. This too should be addressed by the examiner. Finally, the Veteran and her representative have submitted medical articles regarding respiratory conditions related to service in Southwest Asia, as well as articles about burn pits and sarcoidosis. The examiner should consider these articles. 2. Service connection for obstructive sleep apnea. The Veteran contends that she began to suffer from sleep apnea in service, and that it is secondary to her PTSD. The Veteran underwent a VA examination in March 2018. The examiner stated that the Veteran’s sleep apnea is less likely than not caused by her breathing problems. Remand is necessary to properly address her claims. The examiner did not address whether the Veteran developed sleep apnea during service, as separate from her claimed breathing problems. The Veteran submitted an article addressing the relationship between sleep apnea and service in Southwest Asia. Further, the examiner should address whether the Veteran’s sleep apnea is caused by or aggravated by her service-connected PTSD. 3. Service connection for hypertension. The Veteran contends that her hypertension was aggravated by her military service as she was diagnosed in 1992 after a pregnancy. Service treatment records demonstrate that the Veteran sought treatment for high blood pressure in service, to include a report of concerns over her high blood pressure right before separation from service during her period of active duty from June 2004 to April 2005. A VA medical opinion is necessary to determine if her military service aggravated her hypertension. Further, the examiner should address whether her service-connected PTSD aggravates her hypertension. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to treatment for a breathing disorder, sleep apnea, and hypertension. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination regarding her claimed breathing disorder. The articles submitted by the Veteran in November 2017, November 2018, and December 2020 should be reviewed by the examiner. The examiner is asked to address the following: (a) What are the currently diagnosed respiratory disorders? The examiner should specifically address if the Veteran has sarcoidosis. (b) Did any current respiratory disorder clearly and unmistakably pre-exist the Veteran’s entry into active service in August 1980, June 2004, or October 2011? If so, please explain the basis for this conclusion and list the specific disorder(s) that pre-existed the period(s) of service. (c) For any current respiratory disorder that pre-existed a period of service, is it clear and unmistakable that the disorder did not increase in severity beyond its natural progression as a result of the period of service? If so, please explain the basis for this conclusion. (d) For any current respiratory disorder that did not pre-exist service, is it at least as likely as not that the disorder is related to an in-service event, injury or disease, to include service in Southwest Asia and exposure to burn pits? (e) Does the Veteran have any objective signs of a breathing disorder that are not accounted for by any diagnosed condition? If so, please list each sign/symptom and address the level of impairment and whether it is at least as likely as not that any sign/symptom is related to an undiagnosed illness or to a medically unexplained chronic multi-symptom illness as a result of the Veteran’s service in Southwest Asia. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current sleep apnea onset during active service from June 2004 to April 2005 or October 2011 to October 2012 or is otherwise related to an in-service injury, event, or disease, to include as due to service in Southwest Asia and exposure to burn pits. The examiner should also address whether the current sleep apnea is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected PTSD. The articles submitted by the Veteran in November 2017 and December 2020 should be reviewed. In the Veteran’s August 2018 VA Form 9, she asserts her breathing problems began in 2005 while deployed to Iraq and her roommate would wake her up at night because she could not hear her breathing. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 4. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current hypertension increased in severity during the Veteran’s active service from June 2004 to April 2005 or October 2011 to October 2012. If so, the examiner should address whether it is clear and unmistakable that the increase in severity was due solely to the natural progression of her hypertension. The examiner is asked to consider the fact that the Veteran noted her high blood pressure as a concern in April 2005 after her deployment to Southwest Asia. She also testified that during that deployment she was placed on a different blood pressure medication than she had been previously taking and believes she had an allergic reaction. She further testified to having an episode while deployed where she developed an eye hemorrhage, which she believes may be related to her blood pressure. The examiner should also address whether the current hypertension is at least as likely as not aggravated by (worsened beyond natural progression) service-connected PTSD. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Hofmeister, Attorney Advisor 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.