Citation Nr: 21023991 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 14-43 578 DATE: April 21, 2021 REMANDED Entitlement to service connection for sleep apnea (OSA) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1989 to March 201. This matter comes before the Board of Veteran’s Appeal (Board) on appeal from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded in December 2018 and September 2020 for further development to include a VA examination. The case has now returned to the Board for appellate review and, although it again regrets the further delay, the Board finds that additional remand is required. Entitlement to service connection for the Veteran's sleep apnea is remanded. Here, the Board finds that the January 2021 examiner’s medical opinion is not in compliance with the Board’s September 2020 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the Board directed the examiner to explain why the Veteran’s PTSD was not a cause or aggravator of his claimed OSA. The January 2021 examiner explained that the Veteran has the highest known risk factors for OSA including obesity, increased neck size, and significant history of alcohol use. The examiner stated that the Obstructive Sleep Apnea and Posttraumatic Stress Disorder medical article found that Veterans with PTSD and no other known risk factors are at a higher risk of developing OSA. However, the January 2021 examiner failed to adequately explain why the presence of the other risk factors makes it improbable that the Veteran’s PTSD caused and/or aggravated his OSA. Further, the examiner did not address the Veteran’s contention that his ex-wife told him that while he was in service, he stopped breathing while asleep and began snoring. See January 2021 VA Examination Report. Additionally, the January 2021 examiner stated that there was no medical evidence showing that the Veteran’s OSA was aggravated beyond its natural progression by his PTSD, but also found that no baseline could be seen for the Veteran’s OSA other than the 2012 sleep study. However, the examiner failed to address whether the Veteran’s OSA has been aggravated beyond its natural progression, especially in light of the Veteran’s inability to use his CPAP because he is claustrophobic. See January 2021 VA Examination Report. As the opinion obtained on remand is inadequate, the Board finds that a VA addendum opinion is warranted. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).  The VA addendum opinion must adequately explain why the Veteran’s other known risk for OSA makes it less probable that his OSA was not caused by or aggravated by the Veteran’s PTSD. The examiner should adequately address the Veteran’s in-service complaints of snoring and that he stopped breathing while sleeping and determine whether these were symptoms of his later diagnosed OSA. Lastly, the examiner should determine whether the Veteran’s OSA was aggravated based on the Veteran’s inability to use his CPAP machine. In ordering a remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran’s lay reports.  Rather, the Board is merely requesting that the examiner on remand consider the Veteran’s own descriptions of the history of his OSA disability.  See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). The matters are REMANDED for the following action: 1. The RO should send the claims file to an appropriate VA examiner who has not previously participated in this case for an addendum opinion as to whether the Veteran’s OSA is related to service and/or caused by or aggravated by the Veteran’s service-connected PTSD. The claims file, including a copy of this Remand, must be made available to and be reviewed by the examiner in conjunction with the examination. If a clinical evaluation is deemed necessary to answer the questions presented, one should be scheduled. The claims file, and a copy of the remand, must be reviewed by the examiner. A notation indicating that the claims file and remand was reviewed should be included in the examination report. Following review of the file and this remand, the examiner is to address the following: (a.) Please state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s OSA disability was caused by the service-connected PTSD condition. (b.) Please state whether it is at least as likely as not that the Veteran’s OSA disability was aggravated by his service-connected PTSD condition. Here, aggravated means worsened beyond the natural progression of the condition. (c.) Please state whether the Veteran’s in-service complaints that he stopped breathing while sleeping and snored coupled with trouble sleeping were or were not early symptoms of the Veteran’s OSA disability. For the purpose of providing the opinion requested, state whether a nexus between the Veteran’s OSA and service is medically consistent with the information provided by the Veteran. (The Board reminds the Veteran that in asking the examiner to accept the history he provided, the Board is not at this time making an assessment of the credibility of his statements). (d.) Please state whether the Veteran’s PTSD could have caused the Veteran’s OSA, even if other known risk factors are present. If not, please explain why the other risk factors are weighed heavier than the Veteran’s PTSD. In providing this opinion, please review the medical literature entitled Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans by Colvonen, P.J., Masino, T., Drummond, P.A., Myers, U.S., Angkaw, A.C., & Norman, S.B. (2015). Journal of Clinical Sleep Medicine. (e.) Please determine whether there is any aggravation of the Veteran’s OSA seeing that Veteran stated that he cannot use CPAP machine. See January 2021 VA Examination Report. In offering any opinion, the examiner should consider medical and lay evidence dated both since the filing of the claim (April 2012) including but not limited to the January 2021 VA Examination. The examiner should provide a complete rationale for any opinion rendered. If the examiner’s opinion is negative, he or she must clearly explain why. If he or she cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why that is so. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.Foster, 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.