Citation Nr: 21024470 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 12-10 173 DATE: April 22, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to June 1971. This appeal comes to the Board of Veterans Appeals (Board) from a June 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In September 2016, in April 2019, and in December 2020, the Board remanded the claim for further development. Entitlement to service connection for OSA is remanded. The Veteran, and his representative, contends that his OSA is related to service. In the alternative, the Veteran’s representative also argues that his OSA is secondary to his service-connected posttraumatic stress disorder (PTSD). See Appellate Brief (April 2021). The representative additionally maintains that the Veteran’s OSA is secondary to his service-connected lumbar spine disability or nonservice-connected cervical spine disability. See Appellate Brief (November 2020). To ensure that VA has met its duty to assist, the claim must be remanded for further development. Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, the medical evidence of record is inadequate to decide the claim on appeal. As an initial matter, the Board notes that, in December 2020, the claim was remanded for a VA medical opinion. Although a VA medical opinion was obtained in February 2021, and addendum opinion in March 2021, the medical opinions, however, are inadequate as the essential rationale for the conclusions is not discernable. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). In this regard, the February 2021 opinion, and March 2021 addendum opinion, reflect the following conclusions: (1) The Veteran’s OSA less likely than not had its onset in service, or is otherwise related to an in-service injury, event, or disease during service. (2) The Veteran’s OSA is less likely than not due to or the result of his service-connected PTSD. (3) The Veteran’s OSA is less likely than not aggravated beyond its natural progression by his service-connected PTSD. In support of the conclusions, the opinions note that available records were reviewed, to include service treatment records (STRs). With regard to finding that the Veteran’s OSA did not have its onset in, or was related to, service, the medical opinions note no credible causation in the record, and that his STRs were absent of subjective evidence of significance, such as evidence indicating waking up and gasping for air, and witnessed apneas; further, the opinions also noted that his STRs did not show objective evidence of an onset of OSA during service, which would include evidence such as a sleep study in order to make the diagnosis or have suspicion that it existed without diagnosis. In finding that the Veteran’s OSA is not proximately due to, or aggravated beyond its natural progression by, service-connected PTSD, the February 2021 medical opinion first noted that available records were reevaluated and that: [t]he current medical literature remains silent for any mechanism by which PTSD (a psychiatric disorder) may cause or aggravate treated [OSA] which is caused by the muscles that support the soft tissues in your throat, such as your tongue and soft palate, temporarily relax. When these muscles relax, your airway is narrowed or closed, and breathing is momentarily cut off. In this instance, the above opinions reflect medical findings and conclusions. The opinions, however, do not reveal reasoned rationales or medical explanations supporting the reached conclusions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“a medical opinion . . . must support its conclusion with analysis that the Board can consider and weigh against contrary opinions”). Indeed, at most, the Board is able to ascertain the opinions’ medical findings and conclusions, however, the essential rationale connecting the medical findings to the conclusions is not discernable and the Board is not competent to substitute its own medical rationale for that of the opinion. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Second, the February 2021 VA medical opinion noted that the current medical literature does not show that PTSD “may cause or aggravate treated [OSA].” However, the opinion does not provide or reflect consideration of facts specific to the Veteran vis-à-vis the medical literature that was reviewed. See Bailey v. O’Rourke, 30 Vet. App. 54, 60 (2018) (stating that a medical rationale based solely on general medical literature without discussing the specific facts pertaining to a veteran’s condition or individual circumstances is inadequate). Further, the opinion appears to reflect the same analysis for the theories of causation and aggravation. Indeed, the opinion does not show distinct analyses for the independent concepts. See Atencio v. O’Rourke, 30 Vet. App. 74, 90-91 (2018) (holding that a medical opinion was inadequate when it was unclear whether the examiner had clearly provided a rationale that dealt with causation and aggravation as independent concepts). Given the above, the Board may not rely upon the VA medical opinions in their present form and, therefore, finds the medical evidence is inadequate for adjudicative purposes. Where VA provides an examination or obtains an opinion, it must be adequate. Barr, 21 Vet. App. 303. Accordingly, as the Board has a duty to ensure compliance with the terms of its remand, remand is again required. Stegall v. West, 11 Vet. App. 268 (1998). In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from February 2021 to the Present. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s OSA. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran’s reported symptoms, including the nature, onset, progression and severity of any symptom consistent with his OSA. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to the following: Direct Service Connection (a) Whether the Veteran’s OSA at least as likely as not (1) had its onset in service, or (2) is otherwise related to an in-service injury, event, or disease during service. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. Secondary Service Connection (b) Whether the Veteran’s OSA is at least as likely as not (1) proximately due to service-connected PTSD, or (2) aggravated beyond its natural progression by service-connected PTSD. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address the cited medical literature, to include “The Connection Between Sleep Apnea and PTSD,” Sleep Foundation, Foley L, February 2021. See Appellate Brief (April 2021). Explain. (c) Whether the Veteran’s OSA is at least as likely as not (1) proximately due to service-connected lumbar spine disability, or (2) aggravated beyond its natural progression by service-connected lumbar spine disability. Provide a rationale that deals with causation and aggravation as independent concepts. Explain. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 3. Ensure that the VA medical opinion obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Griffey, 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.