Citation Nr: 21026506 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 15-44 589 DATE: May 3, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as second to PTSD is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Army from September 1969 to December 1970, including a tour of duty in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the electronic claims file. The Board remanded the claim for service connection for obstructive sleep apnea to the Agency of Original Jurisdiction (AOJ) in May 2019 to conduct additional development of the record, including obtaining a VA medical opinion. In December 2020 the Board, after review of the record, found there had not been substantial compliance with the May 2019 remand orders and that additional remand was necessary. Unfortunately, the Board feels that another remand is needed. Entitlement to service connection for obstructive sleep apnea (OSA), to include as second to PTSD is remanded. The Veteran contends service connection is warranted for obstructive sleep apnea. After review of the evidence, a remand is necessary to allow the Board to make a fully informed decision. The Veteran's newest theory of service connection as expressed in his April 2021 Appellate Brief is that his sleep apnea is linked to his service-connected PTSD because his PTSD manifests with chronic sleep impairment, and that chronic sleep impairment is linked to obesity, and that obesity is linked to sleep apnea. The January 2021 VA opinion attributes the sleep apnea to obesity. Obesity in of itself is not a disability eligible for service connection. Marcelino v. Shulkin, 29 Vet. App. 155 (2018). That notwithstanding, obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). See VAOPGCOREC 1-2017. The Board needs a medical opinion to know if the Veteran's obesity was caused by or made worse by his service-connected PTSD. The matter is REMANDED for the following action: 1. Associate any VA treatment records since January 2021 with the Veteran's electronic claims file. 2. After completion of the above-specified development, obtain an addendum medical opinion on the etiology of the Veteran's obstructive sleep apnea. The examiner must have the appropriate expertise and be provided access to the electronic claims file. The examiner must indicate review of the claims file in the examination report. If the VA examiner determines that an additional examination of the Veteran is necessary to provide reliable opinions as to causation, such examination should be scheduled; however, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The examiner is asked to provide the following opinions after referencing the following medical treatises put forth by the Veteran's representative in support of his theory of the claim. 1. Bonnet, M.H., and Arand, D.L. Risk Factors, Comorbidities, and Consequences of Insomnia in Adults, and 2. Farr O.M., Sloan D.M., Keane T.M., Mantzoros C.S. Stress-and PTSD-associated Obesity and Metabolic Dysfunction: a Growing Problem Requiring Further Research and Novel Treatments. Metabolism. 2014; 63(12):1463-1468. doi:10.1016/j.metabol.2014.08.009: a) Is it at least as likely as not (50 percent probability or greater) that the current sleep apnea had onset in service or is etiologically directly related to active service? The examiner must discuss lay report of snoring in service. b) Is it at least as likely as not (50 percent probability or greater) that the current sleep apnea is caused by the Veteran's service-connected disabilities, including PTSD? The examiner must discuss the February 2018 opinion of Dr. P.T. c) Is it at least as likely as not (50 percent probability or greater) that the current sleep apnea is caused by or worsened by the Veteran's obesity? d) Is it at least as likely as not (50 percent probability or greater) that the Veteran's obesity is caused by or worsened the Veteran's PTSD? If the VA examiner opines that the sleep apnea is somehow aggravated by the PTSD, he/she should indicate the degree of disability before aggravation and the current degree of disability. A rationale should be given for all opinions and conclusions rendered. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Black, 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.