Citation Nr: 21027730 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-63 597 DATE: May 6, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from February 1968 to November 1979. 1. Entitlement to service connection for obstructive sleep apnea is remanded. In the September 2020 remand, the Board requested a medical opinion addressing several avenues to service connection for the Veteran's sleep apnea. Although the Agency of Original Jurisdiction (AOJ) obtained the requested opinions, remand is again required to obtain adequate opinions. Specifically, the December 2020 examiner found that the Veteran's sleep apnea was less likely than not related to service finding no causal relationship between a sleep disturbance 30 years prior and the diagnosis of obstructive sleep apnea. The examiner appears to be referencing the Veteran's reports of in-service snoring and sleep symptoms. However, the rationale fails to acknowledge the lay evidence of sleep symptoms and is based solely on the lack of diagnosis for many years, which is inadequate. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Additionally, the examiner provided negative opinions on secondary service connection from asthma finding that medical literature and the disease process of sleep apnea did not support a causal relationship. Nevertheless, the examiner noted that asthma can increase the risk of development of sleep apnea. The examiner failed to provide adequate explanation as to whether service-connected asthma could have contributed to or aggravated (worsened) the Veteran's sleep apnea and if so, to what degree. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Finally, the Board requested an opinion as to the role obesity may have played in the etiology of the Veteran's sleep apnea, particularly in light of treatment records referencing weight as impacting his sleep apnea. While obesity is not considered a disability for VA compensation purposes, obesity may act as an intermediate step where a disability would not have occurred but for obesity caused or aggravated by a service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). The examiner found that obesity is less likely than not proximately due to or the result of any of the Veteran's service-connected conditions because they are not medially related and obesity is a separate entity entirely. The Board finds this opinion also inadequate as the examiner failed to provide detailed rationale. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). The examiner noted that obesity is a risk factor for the development of sleep apnea, and obesity is caused by the intake of more calories than the number of calories burned in a day. However, the examiner failed to adequately explain whether the Veteran's service-connected disabilities most notably asthma, lumbosacral strain, and posttraumatic stress disorder (PTSD) could have impaired his ability or motivation to exercise or altered his eating habits such that they caused him to intake more calories than he burned. The AOJ should obtain a new medical opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. Obtain a new medical opinion on the Veteran's sleep apnea. The examiner should review the claims file and address the following: (a.) Is the Veteran's sleep apnea at least as likely as not related to his service? Consider the Veteran's reports of snoring and other sleep symptoms observed during service and in the years after service before diagnosis. (b.) Did the Veteran's service-connected asthma at at least as likely as not contribute to the development of or aggravate (worsen) his sleep apnea? If so, please express the degree of contribution or aggravation based on a percentage. Consider all relevant evidence, including the article submitted in October 2016. (c.) Did the Veteran's service-connected disabilities, including lumbosacral strain, asthma, and PTSD, at least as likely as not cause obesity, through impairment in ability to exercise, altered diet and motivation, etc.? (d.) Did the Veteran's service-connected disabilities, including lumbosacral strain, asthma, and PTSD, at least as likely as not aggravate (worsen) his obesity, through impairment in ability to exercise, altered diet and motivation, etc.? If aggravation is found, provide a baseline level of disability prior to aggravation. (e.) Was the Veteran's sleep apnea at least as likely as not caused by obesity? Is it at least as likely as not that the Veteran not have sleep apnea but for obesity? All opinions must be supported by detailed rationale. If the opinion cannot be provided without resort to speculation, the examiner should explain why, and state whether the inability is due to the absence of evidence or limits of scientific/medical knowledge. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.P. Armstrong 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.