Citation Nr: 22012191 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 17-16 326 DATE: March 2, 2022 REMANDED Entitlement to service connection for obstructive sleep apnea, to include secondary to service connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1995 to January 1998. In December 2019, the Veteran testified at a Board hearing. The transcript is of record. In September 2021, the Board remanded the case for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for sleep apnea, to include secondary to service connected PTSD The Board regrets the additional delay; however, a remand is necessary for further development. In September 2021 the Board remanded this case to obtain a VA medical opinion addressing direct and secondary service connection. The examiner provided a negative nexus opinion finding no evidence of obstructive sleep apnea in service and concluding that psychological comorbidities do not cause or aggravate obstructive sleep apnea. The examiner noted that despite the Veteran's specified complaints of "snoring and gasping, etc." in service it is less likely than not that his sleep apnea had its nexus in service or was aggravated beyond its natural course by PTSD. The examiner also concluded that it is implausible that an individual could have endured 17 years without seeking care for the condition had the nexus arisen in service. The Board finds that an addendum opinion is necessary to explain why the reported symptoms of snoring, gasping/cessation of breathing, and daytime fatigue during service are not indicative of a nexus in service or aggravation by PTSD. The examiner noted that many conditions could contribute to these general symptoms and generally cited medical knowledge to support the conclusion that there is no physiologic or anatomic mechanism by which PTSD, or medications used to treat it, could cause or aggravate obstructive sleep apnea. Further explanation is required as a rationale must go beyond a generalized statement that a review of medical literature does not support the Veteran's claim and should reflect the specific facts and medical principles applicable to the Veteran's claim. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Additionally, the Veteran provided several articles challenging the rationale provided by the VA examiner. An article from the Mayo Clinic noted that individuals with obstructive sleep apnea may be unaware of interrupted sleep and not realize they have not slept well at night; thus, suggesting that an extended length of time from separation to diagnosis may be plausible. See https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms-causes/syc-20352090. The Veteran also provided articles indicating an association between PTSD and sleep apnea, to include a study finding that PTSD severity increased the risk of screening positive for obstructive sleep apnea. See https://www.ncbi.nlm.nih.gov/pubmed/25665698. Furthermore, the Veteran contended that his PTSD symptoms and medications caused weight gain, which resulted in sleep apnea. The medical records reflect complaints that the Veteran's medications made him gain weight, which in turn made his sleep apnea worse. The Board notes that the February 2021 VA examiner provided a negative nexus opinion explaining that the Veteran had several risk factors for sleep apnea, to include obesity. 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); VAOPGCREC 1-2017. Secondary service connection may be warranted if (1) the service-connected disability caused the Veteran to become obese, (2) the obesity was a substantial factor in causing or aggravating a subsequent disability, and (3) the subsequent disability would not have occurred but for obesity. See Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). Thus, a remand is necessary for an opinion to address whether secondary service connection based on obesity as an intermediate step is warranted. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Acquire updated VA and/or private treatment records. If such records are unavailable, the Veteran's claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's obstructive sleep apnea is related to active service or is caused by or aggravated by military service. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that sleep apnea is proximately due to or the result of the Veteran's service-connected PTSD? (c.) If the answer to (b) is negative, is it at least as likely as not that sleep apnea is aggravated (i.e., permanently or temporarily worsened) by the service-connected PTSD? (d.) If the answers to (b) and (c) are no, is it at least as likely as not (50 percent or greater probability) the Veteran's service-connected PTSD, to include medications for treatment of PTSD caused him to become obese? Did the medications or PTSD affect the Veteran's ability to control caloric intake? (e.) If the answer to (d) is yes, is it at least as likely as not that obesity was a "substantial factor" in causing sleep apnea? (f.) If the answer to (d) is yes, is it at least as likely as not that sleep apnea would not have occurred but for obesity caused by the service-connected PTSD? (g.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. The examiner must consider and address the lay evidence reporting snoring, intermittent cessation of breathing during sleep, and daytime fatigue during active service. See Buddy/Lay Statement February 2020. The examiner must also address the articles provided by the Veteran suggesting a link between PTSD and obstructive sleep apnea and the article explaining why there may be a delay in obtaining a diagnosis of obstructive sleep apnea. See Appellate Brief August 2021 and February 2022. The opinion and rationale must go beyond a generalized statement that a review of medical literature does not support the Veteran's claim. The rationale should reflect the specific facts and medical principles specific to the Veteran's claim. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.