Citation Nr: 21041877 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 17-62 259 DATE: July 10, 2021 REMANDED Service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active duty from June 1957 to February 1961. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2017 decision. In April 2018, the Veteran had a hearing before the undersigned VLJ; a transcript of the hearing is of record. This issue was previously before the Board in June 2018 and April 2021. Secondary Service Connection Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Court held in the case of Ward v. Wilkie, 31 Vet. App. 233 (2019), that aggravation pursuant to 38 C.F.R. § 3.310 does not require a permanent worsening of the condition. Rather, the Court explained that "aggravation" is any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity hat is above the degree of disability existing before the increase, regardless of its permanence. Id. Furthermore, the Court has held causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Service connection for sleep apnea, to include as secondary to service-connected PTSD, is remanded. Following the Board's June 2018 remand, service connection for PTSD was granted in a January 2020 rating decision. Thereafter, in correspondence received in August 2020 the Veteran's attorney asserted the Veteran's sleep apnea was caused or aggravated by his now service-connected PTSD. In support of this assertion, he submitted an article from the National Institute of Health (NIH) titled "The Correlation of Anxiety and Depression with Obstructive Sleep Apnea Syndrome." Accordingly, in April 2021, the Board remanded the claim for a medical opinion. In an April 2021 opinion, a VA examiner notes the Veteran's attorney is correct that there is a correlation between certain mental health conditions, namely anxiety and depression, and the development of sleep apnea. The examiner goes on to note that a correlation, however, is different than causation. They also note there is a lack of evidence in the medical literature suggesting anxiety (including PTSD) and depression cause sleep apnea. They conclude by noting the Veteran's sleep apnea is central rather than obstructive. For aggravation, the examiner found a lack of evidence in the medical literature establishing that sleep apnea can be aggravated by PTSD. The Board finds the April 2021 VA opinion to be inadequate. While the examiner concluded the Veteran's sleep apnea is central rather than obstructive, the medical record from May 2021 states the Veteran has a history of mild mixed obstructive and central sleep apnea. The matters are REMANDED for the following action: 1. Obtain the Veteran's updated VA treatment records. 2. Obtain an addendum medical opinion for the Veteran's service connection claim for sleep apnea from a VA examiner different than who provided the April 2021 VA opinion. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the opinion. Following a review of the record, to include the Veteran's lay statements as well as any other evidence that may be added to the record concerning onset and recurrence of symptomatology, the examiner should address the following: Whether it is at least as likely as not (50 percent probability or greater) the Veteran's mixed obstructive and central sleep apnea (i) was caused (in whole or in part) or (ii) aggravated (a temporary worsening of a disability or any incremental increase in disability or any additional impairment of earning capacity regardless of its permanence) by his service-connected PTSD as a result of his PTSD symptoms causing poor sleep, interrupting sleep, nightmares, interrupting the use of his CPAP machine, etc. In providing these opinions, the examiner should consider the Veteran's medical records encourage him to use his CPAP device during every sleep episode and for longer sleep periods in order to maximize the benefit of the CPAP therapy and to control the symptoms of his sleep apnea; that his PTSD symptoms include chronic sleep impairment, insomnia, or a difficulty falling or staying asleep and anxiety (see June 2019 Initial PTSD DBQ); and that he has reported trouble falling or staying asleep. See April 2018 Board Hearing Transcript. The examiner should consider whether the Veteran's sleep-related symptoms associated with his service-connected PTSD worsen his sleep apnea symptoms or affect the efficacy of his CPAP machine in controlling his sleep apnea symptoms. For example, in May 2021, the Veteran reported interrupted and poor sleep due to nightmares. The examiner should also consider the NIH article submitted by the Veteran's attorney in August 2020 titled "The Correlation of Anxiety and Depression with Obstructive Sleep Apnea Syndrome." (Continued on the next page) The examiner must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. P. M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Buck Denton 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.