Citation Nr: 22018246 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 16-48 829 DATE: March 28, 2022 REMANDED Entitlement to service connection for a sleep disorder to include sleep apnea, but excluding insomnia, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1986 to August 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision issued by a Department of Veterans' Affairs (VA) Regional Office (RO). The Board remanded the issue on appeal for further development in February 2019 and July 2021. Entitlement to service connection for a sleep disorder to include sleep apnea, but excluding insomnia, is remanded. The Veteran asserts he has a sleep disorder, to include sleep apnea, that had onset in service. He asserts that his currently diagnosed sleep apnea is secondary to his service-connected insomnia or neck disability. He also asserts his sleep apnea is secondary to weight gain caused by his inability to exercise due to his service-connected disabilities. The Veteran is service-connected for several musculoskeletal conditions including intervertebral disc syndrome (IVDS) of the lumbar and cervical spine, bilateral upper and lower extremity radiculopathy, bilateral knee strain, tension headaches, insomnia, and several other disorders. Pursuant to the Board's remand, the Veteran underwent a VA examination for sleep apnea in December 2021. The examiner opined that sleep apnea was not at least as likely as not aggravated beyond its natural progression. She explained that leep apnea does not actually have a natural progression, so determining aggravation is not possible. However, she also indicated that 'for sleep apnea to progress, one would have to likely have a worsening of a known risk factor impacting the individual's sleep. Otherwise, intervention with a CPAP, dental device, lifestyle changes or sleep hygiene changes generally improve sleep apnea. A natural progression of sleep apnea is not found in research literature and would be based upon mere speculation.' A clarifying addendum is needed regarding whether the Veteran's service-connected disabilities aggravated his sleep apnea. That is, whether there has been any worsening of his sleep apnea, no matter how incremental, even if not above and beyond the condition's natural progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). With specific regard to whether the Veteran's sleep apnea had been aggravated by his service-connected disabilities, with obesity as an intermediate step, the examiner opined (with supporting rationale) that the service-connected disabilities did not cause the Veteran's obesity. The examiner did not, however, address whether the service-connected disabilities aggravated the Veteran's obesity. An addendum is needed in that regard. See Id. Lastly, an addendum opinion is also needed regarding the Veteran's qualifying service as a Persian Gulf veteran under 38 U.S.C. § 3.317. A December 2019 VA examiner opined that the Veteran has a sleep disorder that meets the criteria for a diagnosable, chronic multi-symptom illness. The August 2021 VA examiner reported that obstructive sleep apnea is a disease with a clear and specific etiology, and pathophysiology, and diagnosis but also stated, it is outside the scope of his practice to give a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. For this reason, this opinion is afforded no weight as it relates to whether this claimed condition is a Gulf War illness. As there remains no adequate opinion with rationale, an addendum opinion should be obtained. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician. The examiner is asked to review the claims file. The need for an in-person examination is at the examiner's discretion. 1. The examiner is also asked to provide responses to the following: A) Whether the Veteran's obstructive sleep apnea at least as likely as not aggravated beyond its natural progression by his service-connected insomnia. [The examiner is advised that aggravation is defined as any worsening, no matter how incremental, even if not above and beyond the condition's natural progression.] B) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's service-connected disabilities, either alone or in combination, aggravated the Veteran's weight gain or obesity? i. If so, whether it is at least as likely as not that the weight gain or obesity resulting from the service-connected disability or disabilities was a substantial factor in causing or aggravating his sleep disorder. ii. If so, whether it is at least as likely as not that his sleep disorder would have occurred but for weight gain/obesity caused or aggravated by the service-connected disability or disabilities. The examiner should consider the Veteran's lay statements and other evidence of record reflecting that his service-connected disabilities impact his ability to exercise 2. The examiner is also asked to provide responses to the following: A) Is the etiology of the Veteran's sleep apnea (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. B) Is the pathophysiology of the Veteran's sleep apnea (1) inconclusive, (2) partially understood, or (3) fully understood? This determination must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. C) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's sleep apnea was incurred in, or is otherwise related to, his active service? A complete rationale must be provided for all opinions expressed. If the reviewing clinician is unable to provide the requested opinions without resorting to speculation, it must be stated, and he or she must provide the reasons why an opinion would require speculation. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, 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.