Citation Nr: 22016162 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 17-05 792 DATE: March 21, 2022 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 May 1996 to August 1996, from January 2003 to September 2003, June 2004 to August 2005, and from July 2009 to August 2010. In October 2019 and August 2021, this appeal was remanded for further development. Regrettably, the Board finds that a remand is warranted to obtain an addendum opinion to address whether the Veteran's OSA is aggravated by the Veteran's service-connected PTSD. In the present case, the Veteran contends that his OSA is caused by or aggravated by his service-connected PTSD. The Veteran submitted two articles contending that the articles support his contention. In an October 2021 VA medical opinion, the VA examiner opined that the Veteran's OSA is not caused by or aggravated by the Veteran's service-connected PTSD. The rationale provided, however, only discussed why the Veteran's OSA is not caused by PTSD. The VA examiner explained the inherent risk factors for OSA and how OSA is an organic disease and not a mental illness. However, the VA examiner did not provide a rationale as to why the Veteran's OSA is not aggravated by his PTSD. In the November 2021 VA medical addendum opinion, the VA examiner discussed the article submitted by the Veteran (" Sleep Apnea and Anxiety: Is There a Two-Way Connection"), and explained that this article is based on a website blog and is not a scientific, peer reviewed literature to support a causality between PTSD and OSA. In a subsequent November 2021 VA medical addendum, the VA examiner discussed another article submitted by the Veteran ("Sleep Disturbances Associated with Post-Traumatic Stress Disorder") and noted that this article is not peer reviewed and is not physiologic sound. It is a hypothesis and by its own statement, the VA examiner noted, only discusses a correlation of prevalence of OSA with those who have PTSD and not causality. Therefore, the VA examiner concluded that this article does not substantively change his opinion as the fundamental etiology of OSA is anatomic and not psychologic. Upon review of the opinions provided by the October 2021 VA examiner, the Board notes that while the VA examiner discussed why the Veteran's OSA is not caused by his PTSD, the VA examiner did not provide a sufficient rationale addressing whether the Veteran's OSA is aggravated by his PTSD. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (an opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). Significantly, in the October 2021 VA medical opinion, the VA examiner noted a risk factor of OSA that is not necessarily causal is sleep deprivation. The Board notes that a symptom of the Veteran's PTSD is chronic sleep impairment. See December 2016 VA examination report for PTSD. Nevertheless, the VA examiner did not discuss whether the Veteran's chronic sleep impairment as associated with the Veteran's PTSD, which causes sleep deprivation, aggravates the Veteran's OSA. Given such, the Board finds that an addendum opinion is warranted that addresses whether the Veteran's OSA is aggravated by his PTSD, as specifically requested by the Board's previous remand. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. With respect to the Veteran's claim for obstructive sleep apnea (OSA), request an addendum opinion from a qualified medical professional that addresses the following: Whether it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's obstructive sleep apnea (OSA) underwent any incremental increase in disability, regardless of its permanence, due to the Veteran's service-connected PTSD. In providing this opinion, the VA examiner must discuss whether the Veteran's chronic sleep impairment as associated with the Veteran's PTSD, which causes sleep deprivation, aggravates the Veteran's OSA. If the VA examiner relies on medical literature, please apply the medical literature to the specific facts of this case. It is insufficient to make a general statement such as "the medical literature does not support an association between sleep apnea and diabetes." Rather, the VA examiner must explain why the medical literature does not support such an association. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If utilizing references within the electronic claims file, the examiner should clearly provide an identifier. The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the VA examiner must "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Abdelbary, 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.