Citation Nr: 21020774 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 17-54 209 DATE: April 8, 2021 REMANDED Entitlement to secondary service connection for sleep apnea, to include based on aggravation by service-connected adjustment disorder, is remanded. REASONS FOR REMAND The Veteran had active duty service from May 1984 to October 1984, February 2003 to January 2004, and December 2006 to January 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a September 2019 travel Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the electronic claims file. The Veteran is service-connected for an adjustment disorder and is currently diagnosed with obstructive sleep apnea (OSA). He contends that his service-connected adjustment disorder has either caused or aggravated his OSA. Three relevant medical opinions are included in the record. In February 2017, the Veteran requested an opinion from his treating VA physician as to whether his OSA and adjustment disorder with anxiety are linked. His treating physician opined: (1) it is as likely as not that the Veteran had OSA in the military; and (2) it is more than likely that the Veteran’s anxiety is affected by his OSA and poor sleep quality, and anxiety medications such Trazadone can exacerbate OSA. In May 2017, the same treating physician further opined: (1) it is likely that insomnia was caused by the Veteran’s adjustment disorder; and (2) it is more likely than not that the Veteran’s adjustment disorder was caused by his OSA, so long as he had pre-existing OSA. The examiner did not provide rationale for either opinion and while he did address the possibility of the Veteran’s adjustment disorder medication exacerbating his OSA, he did not opine as to whether the medication has in fact aggravated it. In June 2017, a VA examiner reviewed the Veteran’s claims file and opined: (1) the Veteran’s OSA is less likely than not (less than 50 percent) incurred or caused by his difficulty sleeping during the service; and (2) the Veteran’s OSA is less likely than not (less than 50 percent) proximately due to or the result of his adjustment disorder with anxiety. In making this opinion, the examiner referenced medical literature and noted that OSA occurs when the muscles in the back of the throat relax too much to allow normal breathing, a process that adjustment disorder with anxiety has no effect on. The examiner further noted that OSA has certain risk factors, including advancing age, male sex, and a mildly narrowed airway, but not including adjustment disorder with anxiety. Although the examiner considered whether the Veteran’s adjustment disorder caused his OSA, the examiner did not address whether the Veteran’s OSA was aggravated by his service-connected adjustment disorder. The Veteran also contends that his adjustment disorder medications caused his OSA. See October 2017 Statement in Support of Claim. While the February 2017 and May 2017 treating physician noted the possibility of the Veteran’s adjustment disorder medications exacerbating his OSA, her opinion did not include adequate rationale. Separately, the June 2017 examiner did not address the possibility of the Veteran’s adjustment disorder medications causing or aggravating his OSA. Accordingly, the Board finds that a remand is necessary for an adequate VA medical opinion regarding aggravation. The matter is REMANDED for the following action: Forward the Veteran’s claims file to a VA examiner for an opinion. An in-person examination is unnecessary unless otherwise determined by the examiner. After a review of the claims file, the examiner must respond to the following: Is it least as likely as not that the Veteran’s sleep apnea is aggravated by his service-connected adjustment disorder and/or the medication that he is prescribed for his service-connected adjustment disorder? MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Tierno 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.