Citation Nr: 21023314 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-19 754 DATE: April 20, 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 from July 1963 to April 1967 and from October 1984 to July 1987. This matter comes before the Board of Veterans’ Appeals (the Board) on appeal from a March 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his spouse testified at a hearing before the undersigned Veterans Law Judge in April 2019. A transcript is of record. The Board previously remanded this matter in October 2019, and October 2020, for further development.  Unfortunately, as explained below, the Board is not satisfied that there was substantial compliance with its most recent remand; therefore, the appeal must once again be remanded.  See Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008).  Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities is remanded. The Veteran seeks service connection for his sleep apnea, to include as secondary to his other service-connected disabilities. In its October 2020 remand, the Board directed the RO to obtain a supplemental medical opinion to address whether it is at least as likely as not that the Veteran’s sleep apnea was aggravated by his service-connected hypertension. In providing his opinion, the examiner was asked to specifically address medical research cited in the December 2019 VA medical opinion, which indicated a relationship between upper airway reduction and those with resistant hypertension as opposed to controlled hypertension or edema of the lower extremities. The examiner was also asked to address the Veteran’s VA and private treatment records which show a history of uncontrolled hypertension and edema. Regarding the medical literature, the examiner stated that it “speculates” a relationship between sleep apnea and hypertension. However, the examiner did not explain why she believes the research to be speculative. Further, in attributing the worsening of the Veteran’s sleep apnea solely to CPAP non-compliance, the examiner failed to provide the requested opinion whether the Veteran’s sleep apnea was caused or aggravated by his hypertension or edema. Based on the above, the Board finds that the record does not contain a medical opinion that is sufficient to fairly decide the Veteran's claim. Therefore, the claim must be remanded once again because the RO did not comply with the Board's prior remand directive to obtain an adequate medical opinion on behalf of the Veteran. See Stegall, 11 Vet. App. at 268. On remand, an addendum medical opinion must be obtained that is adequate for the Board to make an informed decision on the Veteran’s claim. See Barr v. Nicholson, 21Vet. App.303, 311-12 (2007); Douglas v. Shinseki, 23Vet. App.19, 26 (2009). The matter is REMANDED for the following action: 1. Send the claims file to a VA examiner who has not previously provided an opinion in this case, to provide an addendum medical opinion. The entire claims file, to include a copy of this REMAND, must be provided to the examiner and reviewed in full. Thereafter, the examiner must provide the following opinion: (a.) Is it at least as likely as not that the Veteran’s sleep apnea was caused or aggravated (worsened) by his service-connected hypertension. In doing so, the examiner should address the medical research cited in the December 2019 VA medical opinion indicating a relationship between upper airway reduction and those with resistant hypertension as opposed to controlled hypertension or edema of the lower extremities and the VA and private treatment records that show a history of uncontrolled hypertension and edema. The examiner is advised that the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner must provide a complete rationale for any opinions offered, citing to the examiner’s own expertise, medical principals, and/or evidence in the Veteran’s record, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. (Continued on the next page)   The Board reminds the examiner that failure to comply with the examination directives outlined herein will render the opinion inadequate and will result in further remand of the Veteran’s claim. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Gates 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.