Citation Nr: 21026964 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 16-38 428 DATE: May 4, 2021 REMANDED The claim of entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1994 to March 1999. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2013 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO confirmed and continued the RO's prior denial of a claim for entitlement to service connection for OSA. The Veteran timely appealed the February 2013 rating decision, and in a November 2018 decision the Board reopened the claim and then remanded the claim for further development and adjudicative action. The claim of entitlement to service connection for OSA, to include as secondary to a service-connected disability, is remanded. The Veteran contends that his OSA is related to service, including as secondary to a service-connected disability. Significantly, a review of the record shows that the Veteran was first diagnosed with OSA by sleep study in August 2011 and is currently service connected for posttraumatic stress disorder (PTSD), bilateral pes planus, bilateral knee disorders, bilateral ankle disorders, radiculopathy, a lumbar spine disorder, an eye disorder, a testicular disorder, as well as erectile dysfunction. The Veteran has been afforded several VA examinations which address whether a link exists between his OSA and a service-connected disability. Significantly, a December 2015 VA examiner opined that the Veteran's OSA was less likely than not caused by his service-connected PTSD as there was no documentation that the Veteran's OSA was aggravated beyond its normal progression by PTSD. The examiner explained that sleep apnea is an obstruction to outflow of air during sleep and that PTSD is a mental problem. The examiner further explained that mental problems do not cause obstruction to outflow of air during sleep. Pursuant to the November 2018 Board remand, an additional medical opinion was obtained to determine whether the Veteran's OSA is caused and/or aggravated by medications he uses to treat his service-connected disabilities. Significantly, a May 2020 VA examiner opined that it was less likely than not that the Veteran's OSA was caused by his service-connected disabilities or medications used to treat his service-connected disabilities. As rationale for this opinion, the examiner noted that the single most important risk factor for developing OSA is obesity and the Veteran's BMI (body mass index) at the time of his diagnosis in April 2011 was 36, indicating obesity. An April 2011 nutrition outpatient education consultation shows that the Veteran's weight gain was due to multiple factors, and not due to an inability to exercise. There was no medical objective evidence that his medications caused significant weight gain to cause obesity. Noted weight between 2011 and 2015 shows no significant weight gain given the presence of service connected conditions and medications, thus indicating the weight problems are more of a lifestyle issue rather than due to a secondary etiology. Furthermore, the Veteran's medical history shows underlying heart disease, high cholesterol, and diabetes, further showing that his diet is likely a major factor in weight problems rather than due to treatment for service-connected disabilities. Subsequently, in October 2020, the Veteran, through his attorney, provided several sources of medical literature addressing a link between PTSD and OSA, including a 2005 study which appears to suggest "[s]leep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries. This association suggests that patients with psychiatric disorders and coincident symptoms suggesting sleep-disordered breathing should be evaluated for sleep apnea." Another study which the Veteran provided stated that: Every clinically significant increase in PTSD symptom severity was associated with a 40% increase in being at high risk for sleep apnea, according to the study published in the May issue of the Journal of Clinical Sleep Medicine." The implication is that veterans who come to PTSD treatment, even younger veterans, should be screened for obstructive sleep apnea so that they have the opportunity to be diagnosed and treated," co-principal investigator Sonya Norman, a researcher at the San Diego VA, said in a news release from the American Academy of Sleep Medicine. This evidence is relevant to whether a link exists between the Veteran's service-connected PTSD and his OSA and was not reviewed by either the December 2015 or the May 2020 VA examiners. As such, a new opinion must be obtained which addresses whether a link exists connecting the two conditions, and which opinion considers the evidence provided by the Veteran in October 2020. The matter is REMANDED for the following action: Return the claims file to the May 2020 VA examiner VA OSA examiner for an addendum opinion. If the examiner who drafted the May 2020 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner should confirm the Veteran's diagnosis of OSA. Thereafter, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's OSA was caused by, or aggravated by, (i.e., chronically worsened), his service-connected PTSD. In forming any opinions, the examiner should address the relevance of the medical literature which the Veteran provided in October 2020 concerning a link between OSA and PTSD. APRIL MADDOX 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.