Citation Nr: 21032468 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-03 235 DATE: May 27, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected post-traumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1968 to November 1970, to include service to Vietnam. The Veteran was awarded a Combat Action Badge among other awards and decorations. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision issued by the Department of Veterans Affairs (VA) regional office. The matter was most recently remanded in April 2019 and has returned to the Board for further adjudication. In November 2019, a VA medical opinion was obtained regarding the etiology of the Veteran's obstructive sleep apnea. After review of the record, the examiner provided a negative opinion, noting that the current medical literature does not support that PTSD causes obstructive sleep apnea (OSA). The examiner opined that the Veteran's OSA is more likely due to obesity and the Veteran's age and gender. The examiner noted that the PTSD did not aggravate the OSA disability, as there is no medical literature or evidence that causes a direct connection between the two. The Veteran contends that there is a direct link between PTSD and obesity, and that the obesity was onset by the Veteran's PTSD. The Veteran provide multiple articles that show a link between PTSD and obesity and PTSD and OSA. Obesity may be an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). See VAOPGCPREC 1-2017 (Jan. 6. 2017). As such, a VA medical opinion must be obtained as to whether the Veteran's service connected PTSD caused the Veteran to become obese; whether the obesity as a result of service-connected disability was a substantial factor in causing the Veteran's OSA; and whether the OSA would not have occurred but for obesity caused by the service-connected disabilities. See id. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA medical records dated since May 2020. Any additional pertinent records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. After the completion of the above send the case file to an appropriate examiner for an addendum opinion. If it is determined that an opinion cannot be provided without an examination, one should be scheduled. Based on the examination (including a new one if necessary) and review of the record, the examiner should address the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea was caused by his service-connected PTSD? (b) If the answer to (a) is "no," is it at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea is aggravated by his service-connected PTSD? The opinion provider is informed that aggravation here is defined as any increase in disability. If aggravation is present, the opinion provider should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. (c) The examiner must specifically address the following: (i) whether the Veteran's service-connected PTSD caused the Veteran to become obese; (2) if so, whether the obesity as a result of his PTSD was a substantial factor in causing the sleep apnea; and (3) whether the sleep apnea would not have occurred but for obesity caused by his PTSD disability. The examiner must consider the articles submitted by the Veteran. In offering the opinion, the examiner must discuss the articles and why or why not they were not considered in proffering the decision. 3. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Jarman, 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.