Citation Nr: 21027586 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-48 856 DATE: May 6, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a lung disorder as secondary to sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1968 to September 1972, to include service in the Republic of Vietnam. These matters are before the Board of Veterans' Appeals (the Board) on appeal from an October 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. 1. Entitlement to service connection for sleep apnea, to include as secondary to PTSD is remanded. The Veteran seeks service connection for sleep apnea which he contends either began in or is secondary to his service-connected PTSD. Specifically, the Veteran testified that he experiences nightmares, anger, and aggression caused by his PTSD which make it difficult for him to sleep. The Veteran's wife testified to observing the Veteran's "horrible snoring" since the very beginning of their marriage. Within the first 5 years of marriage, the Veteran's wife started noticing that the Veteran would stop breathing at night. When she would try to wake the Veteran, she recalls it would "just make him angry." At the time of the hearing, the Veteran and his wife had been married for 48 years. See July 2020 Hearing Transcript. The most recent VA medical opinion to assess the nature and etiology of the Veteran's sleep apnea was obtained in August 2017. After reviewing the evidence of record, the examiner found that the Veteran's sleep apnea was less likely than not proximately due to or the result of the Veteran's service-connected PTSD. In light of the July 2020 hearing testimony, and specifically the testimony of the Veteran's wife, that the Veteran has snored since the very beginning of their marriage in 1972, the Board finds that remand is required to obtain a new medical opinion addressing these statements. 2. Entitlement to service connection for a lung disorder as secondary to sleep apnea is remanded. The Veteran has asserted that his lung disorder is secondary to his sleep apnea. As any determination with respect to the sleep apnea claim would materially affect a determination concerning the Veteran's claim for service connection for a lung disorder, this claim is inextricably intertwined with the claim for service connection for sleep apnea, and must therefore be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Accordingly, the matters are REMANDED for the following actions: 1. Obtain an addendum opinion concerning the etiology of the Veteran's sleep apnea and pulmonary fibrosis. A full VA examination should not be scheduled unless deemed necessary by the examiner or otherwise required by the evidence. The examiner must review the Veteran's entire claims file, to include a copy of this REMAND, and note that review in the examination report. Thereafter, the examiner is asked to provide a fully-articulated medical opinion with respect to the following: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's sleep apnea had its onset it or is related to his service; (b) Is it at least as likely as not (50 percent probability or greater) that the Veteran's sleep apnea was caused by service-connected PTSD? (c) If not, is it at least as likely as not (50 percent probability or greater) that the Veteran's sleep apnea was aggravated (worsened) by the PTSD? (d) Is it at least as likely as not (50 percent probability or greater) that the Veteran's pulmonary fibrosis was caused by sleep apnea? (e) If not, is it at least as likely as not (50 percent probability or greater) that the Veteran's pulmonary fibrosis was aggravated by sleep apnea? In providing the requested opinions, the examiner must specifically consider and address the following lay statements: The testimony of the Veteran's wife that when they were first married, she noticed the Veteran's "horrible snoring," and that he was still in the service during this time, for the first few months of their marriage. The testimony of the Veteran's wife that she noticed within the first 5 years of his return from Vietnam, that the Veteran "would stop breathing in the night," and that the Veteran would become angry when she would try to wake him. The Veteran's testimony that his PTSD related to nightmares, anger, and aggression, make it difficult for him to sleep. The March 2017 VA treatment record in which VA physician, P. M, M.D. stated that sleep apnea is known to be linked to PTSD and it is more likely than not that his sleep apnea is directly linked to his PTSD. The March 2017 VA treatment record in which VA physician P.M., M.D. stated that the Veteran has evidence of pulmonary fibrosis which is caused by sleep apnea, and a May 2016 record from Dr. P.M. stating that one of the more common causes of pulmonary fibrosis is untreated obstructive sleep apnea. A detailed rationale for the opinions must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. If the examiner is unable to offer the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to 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. Jones v. Shinseki, 23 Vet. App. 382 (2010). LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Gates 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.