Citation Nr: 21015016 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 15-19 962A DATE: March 16, 2021 REMANDED Entitlement to service connection for an obstructive sleep apnea disability, to include as secondary to sarcoidosis, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1983 to July 1989. The Veteran attended a hearing before the undersigned Veterans Law Judge in September 2019. A transcript of the hearing is of record. This matter was previously remanded by the Board of Veterans’ Appeals (Board) in November 2019 and August 2020. Entitlement to service connection for an obstructive sleep apnea disability, to include as secondary to sarcoidosis, is remanded. The Veteran contends that his current sleep apnea condition is related to his active service. Specifically, the Veteran contends that his current sleep apnea condition was caused or aggravated by his service-connected sarcoidosis. In accordance with the August 2020 Board remand, a medical opinion regarding the etiology of the Veteran’s claimed sleep apnea disability was obtained. The examiner opined that it was less likely than not that the Veteran’s sleep apnea condition was caused by active service. The examiner indicated that a review of the Veteran’s service record noted fatigue, which is due to sarcoidosis. The examiner further noted that no snoring was noted on review of the service record. Therefore, the examiner concluded that it is less likely than not that the Veteran had an obstructive sleep apnea condition related to snoring and fatigue during service. Additionally, the examiner opined that it was less likely than not that the Veteran’s sleep apnea condition was caused or aggravated by his service-connected sarcoidosis. The examiner stated that sarcoidosis is known to cause excessive sleepiness from fatigue independent of sleep apnea. The examiner stated that sarcoidosis generally does not cause obstructive sleep apnea, though it can worsen obstructive sleep apnea. The examiner noted that the Veteran has not undergone further sleep study since April 2012 to help establish a worsening of his sleep apnea condition that can be attributed to sarcoidosis. Therefore, the examiner concluded that it was less likely than not that the Veteran’s sleep apnea condition was aggravated by his service-connected sarcoidosis. An addendum medical opinion was obtained in December 2020. The examiner stated that the Veteran’s lay statements were not born out by his service records. The examiner indicated that there were no reports or symptoms consistent with obstructive sleep apnea noted while in service. The examiner concluded that there is no way to link veteran's statement to service based on the evidence. Additionally, the examiner noted that the Veteran’s sleep apnea condition was not caused by his sarcoidosis medications. The examiner stated that medications are generally not a medically known inducer or cause of sleep apnea, and no evidence to the contrary was noted on review of records. The examiner noted that sarcoidosis medication is not generally linked with sleep apnea. Furthermore, after a review of stated article, the examiner noted that it does not state that sarcoidosis medication causes sleep apnea. The Board finds that remand is warranted for a new sleep apnea examination. The September 2020 examiner opined that it was less likely than not that the Veteran’s sleep apnea was aggravated by his service-connected sarcoidosis. However, the examiner specifically noted that sarcoidosis can worsen obstructive sleep apnea. Furthermore, the examiner did not provide a clear and detailed rationale regarding whether the Veteran’s sleep apnea was aggravated by his sarcoidosis. The examiner merely stated that the Veteran has not undergone further sleep study to help establish a worsening of his sleep apnea condition that can be attributed to sarcoidosis. This suggests that a sleep study would be required in order to fully determine the issue of aggravation. Moreover, although the examiner addressed whether the Veteran’s sarcoidosis medication caused his sleep apnea, it is not clear that the examiner fully considered whether the Veteran’s sarcoidosis medications aggravated his sleep apnea condition. Accordingly, the Board finds that remand is appropriate for a medical examination to determine the nature and etiology of the Veteran’s claimed sleep apnea disability. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination and sleep study to determine the nature and etiology of his claimed sleep apnea disability. A copy of the claims file should be sent to and reviewed by the examiner. Upon review of the file, the examiner is asked to opine as to the following: a. Is it at least as likely as not (i.e., a 50 percent or greater probability) that the sleep disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. The examiner must address the Veteran’s competent lay statements of experiencing sleep apnea symptoms such as snoring and fatigue in service. See VBMS, document labeled Hearing Transcript, receipt date 9/20/2019, page 7. b. Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s claimed sleep apnea disability was caused by his service-connected sarcoidosis? Note that the Veteran is on current medication for his pulmonary sarcoidosis. The examiner should also address the Veteran’s lay statements regarding a potential connection between sarcoidosis and sleep apnea, specifically medications used to treat sarcoidosis and sleep apnea. See VBMS, document labeled Hearing Transcript, receipt date 9/20/2019, page 8; see also VBMS, document labeled Correspondence, receipt date 9/20/2019. c. Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that the Veteran’s claimed sleep apnea disability was aggravated by his service-connected sarcoidosis, to include whether the Veteran’s sleep apnea was aggravated by his pulmonary sarcoidosis medication? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. Note that the Veteran is on current medication for his pulmonary sarcoidosis. If aggravation is shown, the examiner should specify: (1) the baseline manifestations of the disorder found present prior to aggravation; and (2) the increased manifestations which, in the examiner’s opinion, are proximately due to the service-connected sleep disorder, based on medical considerations. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner should note that the lack of a diagnosed sleep apnea disability in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. 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. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David M. Sebstead, 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.