Citation Nr: 21028768 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-24 032 DATE: May 12, 2021 REMANDED Service connection for sleep apnea, to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1998 to April 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA). This case was remanded in October 2018 for further development; it has since been re-assigned to the undersigned. Unfortunately, the Veteran's appeal must be again remanded for further development. The October 2018 Board remand directed the AOJ to obtain an addendum examination and opinions with respect to the etiology of the Veteran's sleep apnea. The remand instructed the examiner to provide a direct service connection opinion specifically addressing the June 1999 service treatment record in which the Veteran sought treatment for sleep disturbance and daytime fatigue and was diagnosed with a possible sleep disorder. Further, the examiner was asked to provide an opinion whether the Veteran's sleep apnea was caused or aggravated by his service-connected disabilities, including depressive disorder, headaches, GERD, nose bleeds, and residuals post status left orbital and maxillary sinus fracture. The Veteran underwent a VA examination in September 2019. The examiner opined that it is less likely than not that the Veteran's sleep apnea is caused by "service event such as sleep disturbance and daytime fatigue because sleep apnea has multifactorial causes therefore it is difficult to pinpoint to one condition that cause[s] sleep apnea. In 1999, claimant had complaints of sleep disturbances, but there are many factors to sleep disturbance. Claimant was not diagnosed with sleep apnea until 2015. He was not diagnosed until approximately 15 years later." The Board finds this opinion inadequate for appellate review. The fact that sleep apnea may have multifactorial causes does not preclude a finding that a service-connected disability may have caused or aggravated the Veteran's sleep apnea. The Board notes that while the examiner states the Veteran was not diagnosed with sleep apnea until 2015, VA medical records show that the Veteran was diagnosed with sleep apnea in November 2013. Regardless, the Board finds that a gap between service and a diagnosis is not dispositive, particularly considering the Veteran's lay statements regarding the Veteran's continuous sleep problems since service. Moreover, it does not appear that the examiner considering the Veteran's assertions of continuity of symptoms since service. The Board finds these contentions to be credible. An opinion based on these facts is inadequate. As a result, remand for an addendum opinion is necessary. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner opined that the Veteran's sleep apnea was less likely than not caused by depressive disorder, headaches, GERD, nose bleeds, and residuals post status left orbital and maxillary sinus fracture because: "sleep apnea is a multifactorial causes therefore it is difficult to pinpoint one condition that causes sleep apnea. None of the listed would have effected the passage of the airways, also they were all after service." The examiner provided the same rationale regarding whether the Veteran's sleep apnea was aggravated by any of his service-connected disabilities, stating "none of the listed conditions effect the nasal passage to cause aggravation to obstruction." The Board also finds this opinion inadequate for appellate review. First, it uses the same reasoning as the direct service connection opinion. The fact that sleep apnea may have multifactorial causes does not preclude a finding that a service-connected disability may have caused or aggravated the Veteran's sleep apnea. Second, the opinion provided is vague and lacks any specific analysis or reasoning. Third, the fact that the Veteran's service-connected disabilities occurred after service does not preclude a finding that any of those disabilities may have caused or aggravated the Veteran's sleep apnea. Finally, as causation and aggravation are two separate concepts, the Board finds the identical rationale for both to be inadequately explained. As such, remand for an addendum opinion is necessary. Finally, in correspondence received in September 2020, the Veteran reiterated his contention that his sleep apnea is secondary to his service-connected major depressive disorder. Accompanying the Veteran's statement is a medical study titled "Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort," which addressed whether psychiatric disorders are commonly associated with sleep apnea in Veterans Health Administration beneficiaries. The Veteran contends that this medical literature clearly show a higher incidence of sleep apnea with people with mood disorders, which is how depressive disorders are classified. On remand, the examiner should also address the Veteran's contentions and this medical literature. The matters are REMANDED for the following action: 1. The AOJ should obtain updated VA and non-VA treatment records. 2. The AOJ should obtain an addendum opinion, by a clinician other than the one who provided the September 2019 opinion, to determine the nature and likely cause of the Veteran's sleep apnea. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea was either incurred in or otherwise related to the Veteran's military service? Please explain why. The examiner must specifically address the June 1999 service treatment record in which the Veteran sought treatment for sleep disturbance and daytime fatigue and was diagnosed with a possible sleep disorder. The examiner must consider and discuss the Veteran's lay statements regarding the Veteran's continuous sleep problems since service. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea was caused by the Veteran's service-connected depressive disorder, headaches, GERD, nose bleeds, and residuals post status left orbital and maxillary sinus fracture? Please explain why. (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea was aggravated (worsened) by the Veteran's service-connected depressive disorder, headaches, GERD, nose bleeds, and residuals post status left orbital and maxillary sinus fracture? Please explain why. The examiner should address each service-connected disability separately. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. With respect to the Veteran's service-connected status post left orbital and maxillary sinus fracture, the examiner should address the June 2015 VA examiner's statement that the Veteran's service-connected status post left orbital and maxillary sinus fracture is "attributable to sleep apnea." With respect to the Veteran's service-connected depressive disorder, the examiner should specifically address the medical study submitted by the Veteran in September 2020 titled "Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort," which addressed whether psychiatric disorders are commonly associated with sleep apnea in Veterans Health Administration beneficiaries. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Kerner, 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.