Citation Nr: 18131200
Decision Date: 08/31/18	Archive Date: 08/31/18

DOCKET NO. 17-45 803
DATE:	August 31, 2018

REMANDED
Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD).
REASONS FOR REMAND
The Veteran served on active duty from May 1982 to March 1992.
Although this appeal was previously remanded in May 2018 to obtain an addendum opinion, to include as to whether the Veteran’s obstructive sleep apnea was proximately caused by or aggravated by his service-connected PTSD, the Board finds that the June 2018 medical opinion is inadequate for the following reasons.
In the June 2018 VA examination report for sleep apnea, the VA examiner opined that the Veteran’s obstructive sleep apnea is less likely than not caused by his service-connected PTSD.  The VA examiner noted that there was a recent study in 2015 that appeared to have shown an association between PTSD and sleep apnea.  This study showed an increased incidence of obstructive sleep apnea in veterans with PTSD and that increasing severity of PTSD increased the risk of testing positive for sleep apnea.  The VA examiner also noted that another study published in 2011 showed that PTSD is not necessarily associated with a higher prevalence of obstructive sleep apnea, however, obstructive sleep apnea may increase PTSD complaints.  The VA examiner further noted that future research is needed to fully verify the exact relationship between PTSD and obstructive sleep apnea, with respect as to whether they just co-exist or whether the exact relationship is etiopathogenically related to the other entity. 
Given the rationale provided, the Board finds that the VA examiner identifies two conflicting studies.  The most recent study provides a positive nexus between obstructive sleep apnea being caused by PTSD, whereas the older study provides that obstructive sleep apnea may increase the severity of PTSD.  However, significantly, the VA examiner stated that future research needed to be conducted in order to fully verify the relationship between PTSD and obstructive sleep apnea.  It remains unclear why the VA examiner relied on the 2011 study rather than the more recent study, in forming the opinion provided.  As the rationale is unclear, the Board finds that it does not have any probative value.  An addendum opinion by a different medical examiner is required. 
The matter is REMANDED for the following action:
1.   Obtain any outstanding VA and non-VA medical records related to the Veteran’s claim for obstructive sleep apnea and associate these records with the claims file.
2.   Schedule the Veteran for a VA examination with a different VA examiner than the June 2018 VA examiner, to determine the onset and etiology of his obstructive sleep apnea.  The examiner is required to review the claims file, and reconcile the studies noted by the June 2018 examiner.  The examiner should provide an opinion to the following:
(a) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s obstructive sleep apnea began in active service; or is due to an injury or disease during such service.
(b) Whether it is as least as likely as not (i.e. probability of 50 percent or greater) that the Veteran’s obstructive sleep apnea is (a) proximately caused by or (b) proximately aggravated by the Veteran’s service-connected PTSD.
Aggravation is defined as a permanent worsening beyond the natural progression of the disease or disability.
If aggravation is found, to the extent possible, the examiner should identify the clinical signs, symptoms, and manifestations of any such disorder which establish: (1) the degree of severity before the onset of aggravation of the cervical spine disability; and (2) the degree of severity at the onset of aggravation of this condition.
The examiner must discuss the Veteran’s lay statements regarding the history and chronicity of symptomatology, to include the Veteran’s ongoing reports that his sleep apnea is caused or aggravated by his PTSD.  S/HE should outline that history in the report.  The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran’s reports of symptomatology, a reason for doing so must be provided.
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).
3. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL.  IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED.  IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION.
 
YVETTE R. WHITE
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	D. Abdelbary, Associate Counsel

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

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