Citation Nr: 21027673 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 19-21 511 DATE: May 6, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1989 to October 1992. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for sleep apnea. The claim was filed on February 2, 2018. In a September 2019 decision, the Board denied the Veteran's claim for service connection for sleep apnea. The Veteran appealed this decision to the U.S. Court of Appeals for Veterans Claims (the Court). In December 2020, the Court granted a Joint Motion for Remand (JMR) filed by the parties which called for a vacatur and remand of the September 2019 decision. As explained below, the Board is remanding this claim for further development, consistent with the instructions in the December 2020 Joint Motion for Remand. Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD) is remanded. The Veteran contends that his sleep apnea is aggravated by his obesity and that the obesity is caused by medication required for his service-connected PTSD. He contends the obesity serves as an intermediate step to secondary service connection. See Walsh v. Wilkie, 32 Vet. App. 300 (2020); VAOPGCPREC 1-2017 (January 6, 2017). In December 2020, the Court granted a JMR to remand the claim for service connection for sleep apnea. The JMR stated that the Board failed to provide an adequate statement of reasons or bases as to the adequacy of the August 2019 VA medical opinion. Specifically, the JMR stated that the August 2019 VA medical opinion failed to address relevant evidence of record which may show a link between the Veteran's weight gain and the medication prescribed for his service-connected PTSD. The Board appreciates the citations to relevant medical literature by the Veteran's representative in the April 2021 brief. While medical article and treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion," such evidence is generally not specific enough to show nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998). In order to comply with the terms of the JMR, an addendum medical opinion must be obtained. The matter is REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records for the period from October 2020 to the present. 2. Obtain an addendum opinion from the August 2019 VA examiner, if available, or another appropriate examiner if the August 2019 VA examiner is not available. The claims file must be made available to the examiner in conjunction with the request. An examination, including via telehealth interview, should only be scheduled if one is found necessary by the VA examiner. The examiner is asked to provide an opinion on the following question: Is it at least as likely as not that the Veteran's diagnosed sleep apnea is (1) caused or (2) aggravated beyond its normal progression by the medication prescribed to treat his service-connected PTSD, with obesity as an intermediate step? In other words, did the medication for the service-connected PTSD cause the veteran to become obese or aggravate his obesity; (2) was the obesity as a result of the PTSD medication a substantial factor in causing or aggravating the OSA; and (3) would OSA have occurred but for the obesity? The examiner should address the medical literature cited in the appellate brief showing an association between OSA and PTSD. The examiner should also address the Veteran's VA treatment records, including but not limited to: (a.) A statement in the VA medical opinion that "The veteran's primary medically accepted risk factors for developing OSA are obesity (BMI 30.9) male sex and advancing age." See Medical Opinion, August 2, 2019, p1; (b.) A statement that the Veteran complained of "significant weight gain and increase in appetite. He has gained 13 pounds since March which coincides with initiation of mirtazapine," and counseling the Veteran to "stop mirtazapine due to weight gain." See, CAPRI, June 13, 2019, p34, 37 (Psychiatrist Note, July 26, 2018); (c.) And a statement in the Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire that the Veteran was "currently prescribed Fluoxetine 40mg daily, and Mirtazapine 7.5 mg daily. He indicates increased appetite and weight gain since starting on his psychiatric medications." See C&P Exam, July 11, 2018, p4. A complete rationale should be given for all opinions and conclusions expressed. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Dean, 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.