Citation Nr: 21026714 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 16-30 157 DATE: May 3, 2021 REMANDED The claim of entitlement to service connection for sleep apnea, including as secondary to service-connected hypertension and/or an undiagnosed or medically unexplained chronic multi-symptom illness, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1990 to June 2007, including in the Southwest Asia theater of operations. His claim comes before the Board of Veterans' Appeals (Board) on appeal of a July 2013 Department of Veterans Affairs (VA) rating decision. The Board remanded this claim to the Agency of Original Jurisdiction (AOJ) in October 2018. The claim of entitlement to service connection for sleep apnea, including as secondary to service-connected hypertension and/or an undiagnosed or medically unexplained chronic multi-symptom illness The Veteran seeks service connection for sleep apnea on one of three bases: direct, as related to service; secondary, as related to his service-connected hypertension; or presumptive basis, as a symptom (sleep disturbance) of an undiagnosed illness. He claims that when he joined the service, he was an All-American football player, but after 100 jumps from an aircraft, an uncountable number of running miles and exposure to all kinds of unidentified chemicals, he developed numerous physical pains that interrupt his sleep. He believes there is evidence of record indicating that his sleep apnea initially arose in service. This evidence shows that he struggled with uncontrollable hypertension during service and later developed related atrial fibrillation despite doctors continuously changing his medication. In late 2010, however, after he began using a CPAP machine, he was able to get his hypertension under control. Prior to post-service surgery for atrial fibrillation, a doctor reportedly told the Veteran that he was in too good of shape to have uncontrolled hypertension and that something else was going on. Now, he knows sleep apnea was interfering with proper control of his hypertension and argues that if a doctor had diagnosed and properly treated his sleep apnea in service, he would have been able to control his hypertension. The Veteran claims that doctors also told him that when he was in the military, little was known about sleep apnea and the effect it had on the body, and as a result, doctors did not test for it; presently, everything clearly shows that the sleep apnea is the underlying reason for his hypertension and the associated irreversible thickening of the walls of his heart. The Veteran asserts that, if he doesn't want things to get worse, he must continue to sleep with his CPAP machine. He questions why, given that the sleep apnea is the underlying cause of his service-related hypertension, the sleep apnea is not also considered related to service. The Veteran does not assert, and the evidence does not establish, that he was diagnosed with sleep apnea during service. A doctor first diagnosed this condition in 2011, approximately four years after service, based on results of a sleep study. In October 2018, the Board remanded this claim to the AOJ for an opinion addressing whether, as the Veteran contends, evidence of his uncontrollable hypertension in service constitutes evidence that the sleep apnea initially manifested then. In July 2018, a VA examiner provided an unfavorable opinion on this case, but the opinion is inadequate. It is based on a lack of a sleep apnea diagnosis during or within one year of service. It does not specifically respond to the question posed by the Board in October 2019. Another opinion is therefore needed pursuant to Stegall v. West, 11 Vet. App. 268 (1998). The matter is REMANDED for the following action: Return this case to the examiner for an addendum opinion on the etiology of the Veteran's sleep apnea. The examiner is requested to opined whether the Veteran's obstructive sleep apnea is (a) at least as likely as not (50 percent or greater probability) related to service; or (b) is related to his service-connected hypertension or (c) is aggravated by his service connected hypertension. The examiner should review all pertinent evidence in the file, including (a) service and post-service treatment records showing uncontrolled hypertension beginning in service, post-service surgery for associated atrial fibrillation, and a 2011 diagnosis of severe obstructive sleep apnea (approximately four years after discharge from service); (b) articles the Veteran submitted in October 2012, which confirm that sleep apnea often goes undiagnosed and increases the risk of high blood pressure and irregular heartbeats; and (v) the Veteran's contention that evidence of uncontrollable hypertension in service constitutes evidence that the sleep apnea initially manifested then. The examiner should specifically acknowledge in writing in the report the Veteran's contention that he has been told by doctors that he was unable to control his hypertension in service due to undiagnosed sleep apnea. The examiner should address generally whether sleep apnea can hinder one's ability to control his or her hypertension. Focusing on the medical evidence of record, the examiner should confirm or refute the Veteran's assertion that the use of a CPAP machine effectively ended his inability to control his hypertension. The examiner should then offer an opinion as to whether evidence of this improvement may be considered evidence that the sleep apnea existed prior to its 2011 diagnosis, including in service. The examiner should provide rationale for each opinion. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. N. 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.