Citation Nr: 21024778 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 16-31 387 DATE: April 26, 2021 REMANDED Service connection for obstructive sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1984 to March 1986, and from November 2009 to October 2010. This case is before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for obstructive sleep apnea. The Veteran timely appealed the June 2015 rating decision, and in October 2018, the Board remanded the case for further development and adjudicative action. The Veteran contends that he has obstructive sleep apnea (OSA) that is related to service. Alternatively, he asserts that he has obstructive sleep apnea that is caused, or aggravated by, his service-connected disabilities including posttraumatic stress disorder (PTSD), asthma, chronic bronchitis, and/or reactive airway dysfunction syndrome. See, e.g. April 2015 NOD. Pursuant to the October 2018 Board remand, a VA examiner was asked to opine as to whether the OSA is at least as likely as not (i) proximately due to or the result of service-connected respiratory disabilities or PTSD; or (ii) aggravated by the Veteran’s service-connected respiratory disorders or PTSD. The examiner reviewed STRs, VA treatment records, private treatment records, and prior sleep apnea examination reports prepared in June 2015 and June 2016. The examiner opined that the OSA is less likely than not directly due to service, or to a service-connected respiratory disorder, because the sleep notes do not document any worsening in OSA from June 2015, when the examiner first evaluated the Veteran, to November 2019. Additionally, the examiner addressed a link between PTSD and OSA, to note that “[s]leep disorders can be associated with PTSD, and likely as not describes the co-occurrence of these two conditions in a patient, but is not stating that one condition caused the other.” The examiner cited a “Director of the local epidemiology research center” who, after reviewing medical literature related to PTSD and sleep apnea, indicated that “[a]ny two medical conditions can overlap to various degrees in a population; a separate question is whether one condition increases the risk of the other. A peer-reviewed publication (J Clin Sleep Med 2012; 8:667) on this topic concluded that PTSD was associated with decreased adherence to treatment for sleep apnea, but not with sleep apnea itself. [sic]” Accordingly, the OSA was less likely than not (i) proximately due to or the result of PTSD; (ii) proximately due to or the result of service-connected respiratory disabilities; or (iii) aggravated by the service-connected respiratory disabilities or PTSD. The examiner also stated her disagreement with the findings of an April 2015 private physician, who noted that the Veteran’s loud snoring daytime somnolence improved with nasal CPAP caused by restrictive lung disease (secondary to toxin exposure during active duty).” While the examiner responded to each question posed to her, opinions which are not supported by adequate rationale carry no probative value, and are insufficient to serve as a basis for denying a service connection claim. In this case, the examiner’s opinions were essentially couched in a finding of no worsening in the OSA from June 2015 to the present; and, finding that although certain disorders such as PTSD may be “associated” with OSA, the evidence does not show that OSA is caused by PTSD. Without more, the examiner’s rationale is insufficient to address the issues at hand; mainly, the examiner provided little to no support or explanation for finding that the Veteran’s OSA is not aggravated by any of his service-connected disabilities, including PTSD and the respiratory disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As so, a remand is necessary to obtain another opinion. The matters are REMANDED for the following action: Obtain an opinion from an appropriate physician regarding the nature and etiology of the Veteran’s obstructive sleep apnea. The Veteran’s electronic claims file should be made available to the examiner for review in connection with his or her opinion. A VA examination may be provided if deemed appropriate. The examiner should provide opinions as to the following: (a) Is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s sleep apnea was incurred in service or is otherwise causally related to the Veteran’s active service or any incident therein? (b) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s sleep apnea was caused by his service-connected PTSD? If not, is it at least as likely as (i.e., a 50 percent or greater probability) that the Veteran’s sleep apnea has been aggravated (i.e., worsened) by his service-connected PTSD? (c) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s sleep apnea was caused by his service-connected asthma, chronic bronchitis, and/or reactive airway dysfunction syndrome? If not, is it at least as likely as (i.e., a 50 percent or greater probability) that the Veteran’s sleep apnea has been aggravated (i.e., worsened) by his service-connected asthma, chronic bronchitis, and/or reactive airway dysfunction syndrome? If aggravation is found as a result of any service-connected disability, the examiner should identify each such disability and identify the baseline level of disability prior to aggravation, to the extent possible, based on the medical evidence as well as any lay statements concerning the severity of the obstructive sleep apnea over time. The examiner must address each opinion requested above, and a thorough rationale should be provided for each opinion which considers the medical records, the Veteran’s unique medical history of obstructive sleep apnea, the medical literature, and the relationship (if one exists) between obstructive sleep apnea and PTSD, asthma, chronic bronchitis, and/or reactive airway dysfunction syndrome. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. KAYS HUKILL 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.