Citation Nr: 21022766 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-04 938 DATE: April 19, 2021 REMANDED Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from August 1969 to September 1993. In February 2019, the Board remanded the Veteran’s service connection claims for sleep apnea, loss of use of creative organ, left lower extremity neuropathy, and right lower extremity neuropathy. The Veteran testified at a hearing before the undersigned Veterans Law Judge in July 2018. A transcript of that hearing is of record. In October 2020, the VA Regional Office (RO) granted the Veteran’s service connection claims for left lower extremity neuropathy and right lower extremity neuropathy. In January 2021, the RO granted the Veteran’s service connection claim for erectile dysfunction. The Veteran was also granted special monthly compensation based on loss of use of a creative organ. As this represents a full grant of the benefits sought, this issue is no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). The only issue remaining before the Board is the Veteran’s claim for service connection for sleep apnea. 1. Entitlement to service connection for sleep apnea is remanded. The Veteran contends that his sleep apnea is directly due to his military service. The Veteran has testified that he first experience symptoms of waking up gasping in-service, that witnesses of his sleep in-service have told him they noticed he has had difficulty breathing while sleeping, and that his now-wife had witnessed the Veteran’s difficulty breathing while sleeping in-service first hand. See July 2018 hearing transcript. Alternatively, the Veteran contends that his sleep apnea is due to a service-connected disability, specifically his service-connected sinusitis. He testified that he initially believed that his symptoms were due to his sinusitis and did not pursue further care in service for these symptoms. Id. Specifically, the Veteran reported the following incidents during service impacted his sinuses which then had an impact on his sleep: falling off a maintenance stand around 1975; a wrench hitting the Veteran’s face; and being hit in the face while playing softball. Id. The Veteran has testified that these symptoms began in military service and have continued up until he reported the symptoms to hs primary care physician in October 2009. Id. In November 2020, the VA examiner opined that the Veteran’s sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The November 2020 VA examiner also opined that his sleep apnea was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected hypertension. The examiner further concluded that the Veteran’s sleep apnea, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. In support of these conclusions, the examiner reasoned that no causal relationship can be established between the Veteran’s sleep apnea and his service-connected hypertension. The examiner reasoned that, although the Veteran reports sleep problems and disordered breathing during military service, the examiner noted that sleep apnea is not documented until 2009, 16 years following separation. The examiner also noted that multiple studies have identified obstructive sleep apnea as a critical risk factor for the development of obesity, diabetes, and cardiovascular disease. In November 2020, the VA examiner also opined that the Veteran’s his sleep apnea is less likely than not (less than 50 percent probability) proximately due to or the result of Veteran’s service-connected disabilities, specifically diabetes, hypertension, and sinusitis. With respect to diabetes, the examiner reasoned that the conditions of sleep apnea and diabetes are not medically related. Specifically, sleep apnea is a separate entity entirely from the diabetes and unrelated to it. The examiner noted that a thorough review of the medical literature failed to demonstrate a causal relationship. Therefore, the examiner concluded that a nexus has not been established. With respect to secondary service connection, the examiner reasoned that the conditions of sleep apnea and sinusitis are not medically related. Specifically, sleep apnea is a separate entity entirely from the sinusitis and unrelated to it. The examiner noted that a thorough review of the medical literature failed to demonstrate a causal relationship. Therefore, the examiner concluded that a nexus has not been established. The Board finds the opinions furnished in November 2020 inadequate. With respect to the opinions regarding the relationship between the Veteran’s sleep apnea and his service-connected conditions, the November 2020 VA examiner did not address whether the Veteran’s sleep apnea was at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected conditions. Therefore, a remand is necessary to obtain adequate opinions regarding the etiology of the Veteran’s sleep apnea. The matters are REMANDED for the following action: 1. Obtain addendum opinions from an appropriate clinician regarding the Veteran’s sleep apnea. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner(s) as part of the examination. A notation to the effect that this review has taken place should be made in the evaluation report. The examiner is asked to provide a response to the following: a. Did the Veteran’s sleep apnea clearly and unmistakably (undebatable) preexist the Veteran’s service b. If the examiner finds it did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service c. If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not (50 percent probability or greater) related to service or related to his service-connected sinusitis or aggravated beyond its natural progression by service-connected sinusitis. Provide a rationale to support the opinion(s). In forming the opinions, the examiner is specifically requested to address the following: a. The Veteran has testified that he first experienced symptoms of waking up gasping in-service, that witnesses of his sleep in-service have told him they noticed he has had difficulty breathing while sleeping, and that his now-wife had witnessed the Veteran’s difficulty breathing while sleeping in-service first hand. Additionally, he testified he initially believed that his symptoms were due to his sinusitis and did not pursue further care in service for these symptoms. b. The Veteran has testified that these symptoms began in his military service and have continued up until he reported the symptoms to hs primary care physician in October 28, 2009. He was diagnosed with obstructive sleep apnea in February 2010. The Board notes that it has accepted this testimony from the Veteran and his spouse as credible. 2. After completing the above action, re-adjudicate the claim. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. E. Grossman, 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.