Citation Nr: 21041260
Decision Date: 07/08/21	Archive Date: 07/08/21

DOCKET NO. 13-22 706
DATE: July 8, 2021

REMANDED

Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from April 1985 to April 1988.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision.  The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in February 2017.  A transcript of that hearing is of record.  This matter was previously remanded by the Board in February 2021.  

1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD is remanded.

Unfortunately, there has not been substantial compliance with the Board's previous remand directive. The February 2021 remand instructed the AOJ to obtain an addendum opinion regarding whether the Veteran's sleep apnea is at least as likely as not proximately due to or aggravated by (defined as any increase in disability) the Veteran's service-connected PTSD. The remand also instructed the clinician to address the contentions laid out in the January 2021 brief that chronic activation of stress hormones caused by PTSD is known to lead a neural sensitization leading to upper airway dysfunction such as sleep apnea, and that psychotropic medications change patterns of brain activity and may directly and indirectly exacerbate sleep apnea and brain stimuli. Unfortunately, the April 2021 opinion used an incorrect definition of aggravation as aggravated beyond its natural progression, and while the clinician recited the contentions from the January 2021 brief, they did not address them or explain why the contentions did or did not apply in this case. Another remand is required.  Stegall v. West, 11 Vet. App. 268, 271 (1998).  

The matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's sleep apnea is at least as likely as not (50 percent or greater probability) (i) proximately due to or (ii) aggravated by (defined as any increase in disability) the Veteran's service-connected PTSD. Copies of all pertinent records must be made available to the examiner for review. 

The opinion offered must be supported by a complete rationale. The clinician must address the contentions laid out in the January 2021 brief that chronic activation of stress hormones caused by PTSD is known to lead to a neural sensitization leading to upper airway dysfunction such as sleep apnea, and that psychotropic medications change patterns of brain activity and may directly and indirectly exacerbate sleep apnea and brain stimuli. It is not enough to simply recite the contentions, the clinician must discuss whether these contentions support a finding that the Veteran's PTSD caused or aggravated his sleep apnea, and why or why not.  

2. The AOJ must 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	A. Budd, 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.