Citation Nr: 25004465 Decision Date: 04/02/25 Archive Date: 04/02/25 DOCKET NO. 14-36 826 DATE: April 2, 2025 REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served in the Army National Guard with verified periods of active duty from June 1983 to August 1983 and November 1990 to April 1991, and additional periods of active duty, active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in February 2018. A transcript of the hearing is of record. These claims were previously before the Board of Veterans' Appeals (Board) in January 2023 and March 2023. In January 2023, the Board (in pertinent part) remanded the claims for service connection for sleep apnea, hypertension and headaches for additional development. Thereafter, in a March 2023 decision, the Board vacated its January 2023 decision as it pertained to the claim for service connection for headaches, only. The reason for vacatur was in remanding that claim, the January 2023 Board decision had contained an error which inadvertently stated the claim was being denied. The March 2023 decision corrected the error, and the service connection claim for headaches was again remanded. Most recently, in December 2024, the Board remanded the above captioned claims again to obtain adequate medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for sleep apnea, headaches and hypertension is remanded. As mentioned, these claims were most recently remanded in December 2024 with clear directives on what was needed to obtain adequate medical opinions for each claim. Unfortunately, despite multiple attempts to obtain an adequate medical opinion for these claims, even the most recent December 2024 VA opinions remain inadequate. While the Board regrets the further delay in the adjudication of these claims, yet another remand is warranted. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Regarding the sleep apnea claim, the most recent December 2024 medical opinion found that the Veteran's sleep apnea was less likely than not directly related to his military service. The examiner explained that based on the review of the available evidence, there was a lack of substantiating evidence to support a nexus between the Veteran's current obstructive sleep apnea and military service. The examiner stated further that without chronicity during service or after service, a post-service event, illness or injury was considered to be a more likely etiology for the Veteran's sleep apnea. In reaching these conclusions, the examiner discussed the Veteran's active duty dates as listed on his DD 214 from June 1983 to August 1983, and noted that the Veteran had additional active duty dates from November 1990 to April 1991. The examiner then stated that the buddy statement from JS regarding the Veteran's snoring in service was from the summer of 2002 which was not during an active duty date. Additionally, the buddy statement from CJ regarding the Veteran's snoring in service had no timelines indicated which the examiner found further supported by the silence in the Veteran's service treatment records (STRs) regarding sleep concerns. The examiner then stated that it was not until sleep studies in 2008 and 2023 that the Veteran's sleep apnea was diagnosed, and these were after his active duty dates. Accordingly, the examiner concluded it was less likely that not that the Veteran's sleep apnea was due to his service as there was a lack of substantiating evidence to support a nexus between the current diagnosis of obstructive sleep apnea and military service. In spite of the December 2024 VA medical opinion, the Board emphasizes that in both the January 2023 and December 2024 remands it was specifically explained that although J.S.'s statement referenced a time period in 2002, and the Veteran's last period of active duty service was in April 1991, the Veteran did have additional periods of active duty, ACDUTRA and INACDUTRA while serving in the Reserves. Additionally, his STRs showed that physical examinations were performed in November 2002, which supported his contention that he was serving in the Reserves for the time period addressed by J.S. The December 2024 VA examiner failed to adequately consider this evidence while rendering the medical opinion. Additionally, the December 2024 VA examiner did not address the Veteran's own statements and assertions that he snored during his military service. For the hypertension claim, the December 2024 VA examiner opined the Veteran's hypertension was less likely as not caused by his military service because there was a lack of substantiating evidence to support a nexus between hypertension and military service. The examiner stated that without chronicity during service, or after service, a post-service event, illness, or injury was considered to be a more likely etiology. The examiner highlighted that the Veteran's STRs were silent for a diagnosis or treatment for hypertension during the Veteran's active duty dates, which the examiner found supported by February 1991 blood pressure reading of 110/78 and the March 1991 Report of Medical Examination which showed normal clinical evaluation with no complaints and no high or low blood pressure documented. The examiner further acknowledged that a slightly elevated blood pressure had been noted during a November 1996 examination, but pointed out this was approximately 5 years after the Veteran's active-duty service period. Based on these facts, the examiner concluded it was less likely than not that the Veteran's hypertension was due to his service. However, as noted in the January 2023 and December 2024 Board remands, the Veteran had additional service in the Reserves. This is particularly important for his hypertension claim because the examiners have failed to specifically address the Veteran's elevated blood pressure readings from November 2002, which was during his service in the Reserves. The recent December 2024 VA medical opinion also identifies a slightly evaluated blood pressure reading from November 1996 and points out this was 5 years after the Veteran's active duty service, but fails to address the November 2002 blood pressure reading which the Board has indicated was during the Veteran's Reserves service. Consideration of these two blood pressure readings is essential to determining whether the Veteran's hypertension was caused or incurred during his military service. Lastly, as for the headache claim, the December 2024 VA medical addendum opinion opined the claimed condition was less likely than not related to the Veteran's active duty service. In support of that opinion, the examiner stated that the Veteran claimed headaches as being directly related to service but "common headache" was not a medically acceptable diagnosis; therefore, a nexus was not established. The examiner explained further that "common headache" was not a medically acceptable diagnosis as it was a non-specific term and did not align with the established diagnostic criteria for headache disorders. The examiner stated that according to the International Headache Society (IHS), headaches were classified into primary and secondary categories. Primary headaches included migraine, tension type headache, cluster headache, and other trigeminal autonomic cephalgia, as well as other primary headache disorders. Secondary headaches were attributed to underlying medical conditions such as vascular disorders, neoplasms, infections, or intracranial pressure abnormalities. Therefore, using a non-specific term like "common headache" is not appropriate. Contrary to the December 2024 VA examiner's finding that the Veteran suffers from "common headaches" only (as found in an August 2023 Headache Disability Benefits Questionnaire (DBQ)), the Board points out that the Veteran was given a diagnosis of migraines, including migraine headaches, by the examiner who conducted the July 2022 VA examination. This diagnosis was not considered by the December 2024 VA examiner. Additionally, as previously highlighted in prior remands, the VA medical opinions of record have not adequately considered the Veteran's lay contentions of suffering from "daily pounding headaches" and experiencing "headaches almost seven days a week for two months" in rendering the negative nexus opinions. The December 2024 VA examiner likewise did not consider these statements in the formulation of her medical opinion, and thus an additional medical opinion is also needed on this basis. For the above reasons, the Board finds that the medical opinions provided for the Veteran's claims for service connection for sleep apnea, hypertension and headaches remain inadequate and unfortunately a remand is again warranted. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion for the Veteran's sleep apnea claim. The examiner must review the claims file (including this remand) and to opine whether the Veteran's sleep apnea is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service. Consideration must be given to the lay assertions from the Veteran, C.J., and J.S., that the Veteran was observed to snore heavily and wake up choking and gasping for air while in service (including during periods of active duty, ACDUTRA and INACDUTRA while serving in the Reserves). 2. Obtain an addendum medical opinion for the Veteran's hypertension claim. The examiner must review this claims file (including this remand) and opine whether the Veteran's hypertension is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service, including the episodes of high blood pressure noted during service (see, e.g. November 2002 STR). Additionally, if service connection for sleep apnea is awarded, the examiner is asked to opine whether the Veteran's hypertension is at least as likely as not due to or aggravated by his sleep apnea. 3. Obtain an addendum medical opinion for the Veteran's headaches claim. The examiner is asked to opine whether the Veteran's headaches are at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service. Consideration must be given to the Veteran's lay assertions of headaches during service. Additionally, if service connection for sleep apnea is awarded, the examiner is asked to opine whether the Veteran's headaches are at least as likely as not due to or aggravated by his sleep apnea. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Churchwell, Kate 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.