Citation Nr: 21013387 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 15-35 973 DATE: March 9, 2021 REMANDED Entitlement to service connection for the Veteran’s sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1988 to April 1991. This matter comes before the Board of Veterans’ Appeals (“Board”) on appeal from a March 2014 rating decision of the Department of Veterans Affairs (“VA”) Regional Office (“RO”). The Board remanded the matter in March 2020 and directed the RO to obtain a VA opinion whether the Veteran’s obstructive sleep apnea is at least as likely as not proximately due to or aggravated beyond its natural progression by service-connected hepatitis C and cirrhosis. Hence, a medical opinion was obtained in October 2020. However, the Board finds the opinion inadequate for deciding the issue on appeal. Regrettably, the Board concludes that further remand is necessary in this matter. Entitlement to service connection for the Veteran’s sleep apnea is remanded. In an April 2019 statement, the Veteran’s representative asserted that the Veteran’s sleep apnea was related to his service-connected hepatitis C and cirrhosis and cited to medical treatise indicating that the risk of obstructive sleep apnea is high among cirrhosis patients. Hence, the Board remanded the matter in March 2020 for obtaining an opinion. Pursuant to the Board’s March 2020 remand, the Veteran was afforded a VA examination and a medical opinion was obtained in October 2020 for determining the nature and etiology of the Veteran’s sleep apnea. The examiner diagnosed the Veteran with obstructive sleep apnea and opined that the Veteran’s sleep apnea is less likely than not proximately due to or the result of the Veteran’s service-connected hepatitis C with hepatosplenomegaly and cirrhosis. The examiner provided the rationale that although evidence suggests that sleep apnea could lead to liver disease, there is not enough evidence to support that hepatitis C with hepatosplenomegaly and cirrhosis results in obstructive sleep apnea. Obstructive sleep apnea is a common disorder characterized by narrowing or collapsing of the pharyngeal airway during sleep due to anatomical variations in the craniofacial features and/or neck, and it is less likely than not due to infectious diseases to include hepatitis C. Regarding aggravation, the examiner opined that there is not enough evidence to suggest that the Veteran’s hepatitis C and cirrhosis aggravated the Veteran’s mild obstructive sleep apnea beyond its natural progression. The Board finds the October 2020 medical opinion inadequate for deciding the issue on appeal. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In March 2020 Board’s remand, the examiner was asked to provide complete rationale for both causation and aggravation, which the examiner failed to address, specifically the causation rationale is conclusory without clear explanation because the examiner just stated that there is not enough evidence to suggest that the Veteran’s hepatitis C and cirrhosis aggravated the Veteran’s mild obstructive sleep apnea beyond its natural progression. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion “must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). The Board also finds that the examiner did not discuss the Veteran’s representative assertions and his cited medical treatise noting that the risk of obstructive sleep apnea and excessive daytime sleepiness is high among liver cirrhosis patients. Hence, a remand is needed to obtain a supplemental opinion with a clear and complete rationale. The matter is REMANDED for the following actions: 1. Forward the claims file and a copy of this remand to the examiner who rendered the October 2020 opinion, or to an appropriate clinician if the October 2020 examiner is unavailable, to obtain a supplemental opinion on the nature and etiology of the Veteran’s sleep apnea. 2. After reviewing the claims file, the examiner is asked to opine whether the Veteran’s sleep apnea is at least as likely as not (i) proximately due to or (ii) aggravated beyond its natural progression by the Veteran’s service-connected hepatitis C with hepatosplenomegaly and cirrhosis, along with clear rationale, not just conclusory statements. The examiner is advised to consider the Veteran’s representative assertions and medical treatise submitted in April 2019 (see page 8 and onwards of document labeled Correspondence, dated 04/15/2019), noting that the risk of obstructive sleep apnea and excessive day sleepiness is high among liver cirrhosis patients. 3. A complete rationale for the opinions rendered must be provided. If the examiner is unable to provide an opinion without resorting to mere speculation, then the examiner must state this and provide any information needed to make an opinion, if possible. 4. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Tariq, Nadeem, Associate Attorney 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.