Citation Nr: 21014382 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 18-09 012 DATE: March 12, 2021 REMANDED Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The appellant served on active duty in the United States Army from June 1989 to December 1989, and from October 2003 to November 2004. He was also a member of the Ohio Army National Guard during which he had periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). This case comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied the appellant’s claim for service connection for sleep apnea. This decision was appealed in a notice of disagreement (NOD) received by VA in November 2015. A Statement of the Case (SOC) was issued by VA in December 2017. VA received the appellant’s Substantive Appeal (Form 9) in February 2018, requesting a hearing before the Board and perfecting the appeal. The appellant appeared before the undersigned Veterans Law Judge at a live tele-hearing in July 2020. A transcript of that hearing has been added to the record on appeal. 1. Entitlement to service connection for sleep apnea is remanded. The appellant contends that his obstructive sleep apnea is at least as likely as not caused by, or aggravated beyond its normal progression by, his service-connected mental health disability. In support of this contention he has submitted several medical articles purportedly indicating a link between combat veterans with PTSD and the development of sleep apnea symptoms. Alternatively, he testified at his July 2020 Board hearing that he developed symptoms associated with sleep apnea, such as snoring at night and daytime hypersomnolence, while he was deployed on active duty between October 2003 and November 2004. After a review of the evidence of record, the Board finds that additional development is necessary prior to adjudicating this claim. In developing the appellant’s claim, he was afforded a VA examination in December 2014. The examiner opined that the appellant’s sleep apnea was not at least as likely as not related to the appellant’s service-connected posttraumatic stress disorder (PTSD); however, the examiner did not provide a rationale for this opinion, merely making a conclusory statement. The examiner noted the appellant did not have any of the typical risk factors for developing sleep apnea, and so the lack of a rationale for the opinion regarding whether PTSD was the cause of the sleep apnea is more glaring. The examiner suggested that a follow up ears, nose, and throat (ENT) examination might reveal some structural impediment causing the sleep apnea such as a deviated septum but did not order or conduct any follow-up testing and/or diagnostic examinations. As such, the Board finds this medical opinion inadequate and finds that a new medical opinion should be obtained. Since the appellant’s VA examination in December 2014, he has submitted several medical journal articles which indicate there is a higher than normal rate of combat veterans with symptoms of PTSD that also experience sleep apnea, which the appellant believes indicates a causal connection. On remand, the VA examiner should address these medical journal articles submitted by the appellant and offer an opinion whether the appellant’s sleep apnea is at least as likely as not caused by, or aggravated beyond its natural progression by, his service-connected PTSD. Finally, the appellant has asserted his symptoms began while he was on active duty. He testified as such at his July 2020 Board hearing. His wife submitted a lay statement in August 2020 which relayed that the appellant had no problem with snoring or breathing while sleeping before his deployment in October 2003, but that the problems began right after his return in November 2004. This raises the question of whether the appellant’s sleep apnea may have begun while he was on active duty, despite it not having been formally diagnosed until 2014. The Board notes the appellant reported no issues with difficulty breathing or denied he was experiencing feeling tired even after sleeping in his post-deployment health assessment. On remand, the examiner should offer an opinion, in consideration of all the evidence of record, as to whether the appellant’s sleep apnea at least as likely as not began while he was on active duty. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the appellant’s obstructive sleep apnea at least as likely as not developed during active service, is at least as likely as not proximately due to the appellant’s service-connected PTSD, or is aggravated beyond its natural progression by his service-connected PTSD. An examination should only be scheduled if deemed necessary by the clinician. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the appellant’s description of his having developed symptoms of snoring and daytime hypersomnolence while on active duty between October 2003 and November 2004, as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the appellant’s reported in-service symptoms represented the onset of his current sleep apnea disability, this should be noted. Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the appellant’s reports generally inconsistent with medical knowledge or implausible? The examiner must discuss the appellant’s lay testimony at his Board hearing and the lay testimony provided by the appellant’s spouse. In rendering an opinion on the question of secondary service connection, or aggravation by a service-connected disability, the examiner must address the medical studies submitted by the appellant which are purported to show a link between PTSD and sleep apnea, particularly in combat veterans. The examiner must also discuss the December 2014 medical opinion which found the appellant did not have any of the typical risk factors for developing sleep apnea. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kleponis, 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.