Citation Nr: 21031982 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 15-01 802 DATE: May 25, 2021 REMANDED Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1973 to January 1978 and from March 1980 to November 1995. In April 2018, the Veteran presented testimony at a videoconference hearing before the undersigned Veterans Law Judge. A transcript is on record. In June 2018, the Board denied the Veteran's claim for service connection for a low back disability and remanded the Veteran's claim for service connection for sleep apnea, to include consideration of the Veteran and his wife's reports of difficulty sleeping beginning in the early 1980s. The Veteran appealed the Board's June 2018 denial to the United States Court of Appeals for Veterans Claims (Court). In a December 2019 order, the Court issued a memorandum decision affirming the Board's June 2018 denial of service connection for a low back disability. Entitlement to service connection for sleep apnea is remanded. This matter must be remanded to obtain an addendum opinion. Service treatment records show the Veteran was diagnosed with insomnia and prescribed sleeping aids during service in February 1982, shortly after his wife had a second child. The first diagnosis of sleep apnea does not appear on the record until 2006. However, during the Veteran's April 2018 hearing and through an April 2018 written statement, the Veteran and his wife testified that since the early 1980s, his wife witnessed apnea-like symptoms, such as snoring, teething grinding, and apnea (i.e., not breathing while sleeping). In May 2019, the Veteran was provided a VA examination on the etiology of his obstructive sleep apnea. The examiner noted a current diagnosis of obstructive sleep apnea, but found it to be less likely than not related to the Veteran's service. However, the Board is unable to confirm whether the examiner based this opinion on a complete factual basis. For example, the examiner characterized evidence while gathering it as the Veteran "states" and the Veteran "reports," specifically that the Veteran "reports he was diagnosed with insomnia while on active duty and prescribed sleep aids." In the subsequent opinion, the examiner states "STRs do not show a history of sleep disturbance/issues." Notably, no where does the examiner acknowledge that the Veteran was in fact diagnosed with insomnia during service. As such, the examiner's opinion appears based on an incomplete factual basis and is thus not probative of whether the Veteran's sleep apnea is related to his military service. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding medical opinions based on incomplete or inaccurate factual premise are not probative). An addendum opinion addressing the Veteran's February 1982 in-service diagnosis of insomnia is warranted. The matter is REMANDED for the following actions: 1. Obtain an addendum opinion from the same examiner who provided the May 2019 opinion, if possible, to determine the etiology of the Veteran's currently diagnosed obstructive sleep apnea. The claims folder must be made available to and reviewed by the examiner. All indicated tests, if any, should be conducted. The examiner must opine, in light of the examination's findings, the service and post-service medical evidence of record, and the lay statements of record, whether the Veteran's currently diagnosed obstructive sleep apnea is at least as likely as not (50 percent or greater probability) causally or otherwise etiologically related to the Veteran's military service, specifically including the Veteran's reported symptoms of snoring, trouble sleeping, stopping breathing, grinding teeth, fatigue, and headaches while in service, as well as his February 1982 in-service diagnosis of and treatment for insomnia. A complete rationale must be provided for any opinion expressed, to include reference to current clinical findings and/or documents in the claims file. 2. Readjudicate the claim. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P.A. Infante, 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.