Citation Nr: 21015222 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 16-53 566A DATE: March 17, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1955 until September 1979. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.902 (c). 38 U.S.C. § 7107 (a)(2). This matter was most recently before the Board in November 2020 when it was remanded for an addendum medical opinion. While the Board regrets the delay, there has not been substantial compliance with the Board’s prior remand directives and another remand is now required. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities is remanded. The Veteran contends that his diagnosed sleep apnea is etiologically related to his service-connected diabetes mellitus, type II, and/or hypertension. The claim must be remanded again because the December 2020 VA opinion is inadequate. The opinion provider reached a negative nexus opinion, but again did not provide an adequate rationale. The examiner commented that “[o]bstructive sleep apnea can potentially aggravate Diabetes mellitus and/or Hypertension but the reverse relationship is not conclusively established in medical literature (emphasis added).” The opinion request specifically asked about the likelihood of a connection (“at least as likely as not”) rather than whether it was conclusive. The examiner also cited a 2003 Article that specifically noted “[s]ome sleep disturbances may result from diabetes through the deleterious effects of diabetes on central control of respiration.” However, the examiner did not address whether that article may support a likelihood of a connection. The opinion provided on remand must consider the standard of proof as posed in the question: whether it is at least as likely as not; not conclusive. On remand, an addendum opinion that is supported by adequate rationale must be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate clinician on the likely etiology of the Veteran’s diagnosed sleep apnea. Copies of all pertinent records must be made available to the opinion provider for review, including a copy of this remand. Based upon a review of the record, and examination or further testing and study, if necessary, the opinion provider is asked to answer the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the diagnosed sleep apnea is proximately due to or caused by his service-connected diabetes mellitus, type II or hypertension? (b.) Is it at least as likely as not (50 percent or greater probability) that the diagnosed sleep apnea is aggravated by (defined as any increase in disability) his service-connected diabetes mellitus, type II, or hypertension? In providing the requested opinion, the opinion provider must consider and discuss the article Diabetes and Sleep Disturbances Findings from the Sleep Heart Health Study, submitted in March 2019. A complete and clear rationale for all opinions must be provided. The examiner is informed that conclusory statements are not sufficient. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. Collins, 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.