Citation Nr: 22018968 Decision Date: 03/31/22 Archive Date: 03/30/22 DOCKET NO. 15-02 091 DATE: March 31, 2022 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), diabetes mellitus, coronary artery disease, and hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to June 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in July 2017. A transcript is of record. The Board most recently remanded the case for further development in September 2021. The case has since been returned to the Board for appellate review Following the most recent remand, the Veteran submitted a statement in December 2021 asserting that his sleep apnea is secondary to his service-connected diabetes mellitus, coronary artery disease, and hypertension. Thereafter, the agency of original jurisdiction (AOJ) obtained additional VA medical opinions in January 2022. Although a VA examiner provided thorough rationale for the opinion that the Veteran's service-connected posttraumatic stress disorder (PTSD) did not cause his obesity, she did not address whether his service-connected PTSD could have otherwise caused his sleep apnea. Nor did she address the aggravation prong of secondary service connection. Similarly, a VA examiner found that the Veteran's service-connected diabetes mellitus, coronary artery disease, and hypertension did not cause obesity, are unrelated to his sleep apnea, and did not aggravate his obesity. However, she did not address whether the Veteran's sleep apnea could have been otherwise aggravated by these additional service-connected disabilities. Therefore, the Board finds that an additional medical opinion is needed. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should refer the Veteran's claims file to a VA examiner for a medical opinion as to the etiology of his sleep apnea. The examiner should review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service VA treatment records, post-service private treatment records, lay statements, and the prior VA examination reports. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should note that the presumption of soundness applies. The examiner should opine as to whether it is at least as likely as not that the Veteran's sleep apnea manifested in service or is otherwise related to his military service, to include any symptomatology therein. In rendering the opinion, he or she should address the lay statements indicating that Veteran had symptoms in service, such as impaired sleep and snoring. The examiner should also state whether it is at least as likely as not that the Veteran has sleep apnea that is either caused by or is aggravated by his service-connected PTSD, diabetes mellitus, coronary artery disease, and hypertension. In this regard, the examiner should note that a rationale is required for both causation and aggravation and that a permanent worsening of the claimed disorder is not required (compensation may be due for an incremental increase caused by the service-connected disability). In rendering this opinion, he or she should explain why PTSD would or would not aggravate sleep apnea even if there are other risk factors. The examiner should also opine as to (1) whether the Veteran's service-connected PTSD, diabetes mellitus, coronary artery disease, and hypertension caused or aggravated the Veteran's weight gain and obesity; (2) if so, whether the causation or aggravation of obesity as a result of service-connected disability was a substantial factor in causing sleep apnea; and (3) whether the sleep apnea would have occurred but for obesity caused or aggravated by the service-connected disabilities. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. The AOJ should ensure that the examination report complies with the foregoing directives. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M. Walker 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.