Citation Nr: 1342881 Decision Date: 12/26/13 Archive Date: 01/07/14 DOCKET NO. 11-21 464 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for sleep apnea syndrome, claimed as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Jeffery E. Marion, Attorney at Law ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active military duty from March 1978 to July 1982. The appeal comes before the Board of Veterans' Appeals (Board) from a May 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, denying service connection for hepatitis C, and from a March 2011 rating decision of the VA RO in St. Petersburg, Florida, denying service connection for sleep apnea. By a July 2011 VA Form 9, the Veteran had requested a videoconference hearing before a Veterans Law Judge of the Board. However, by a signed April 2013 letter the Veteran's authorized representative withdrew that request. FINDINGS OF FACT 1. The Veteran's hepatitis C is not causally related to his period of service. 2. The Veteran's sleep apnea was not caused or aggravated by his service-connected PTSD. His sleep apnea is also not otherwise causally related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis C are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). 2. The criteria for service connection for sleep apnea are not met, including on a secondary basis. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the decision of the U.S. Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006) requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by re-adjudication of the claim, as in a statement of the case (SOC) or supplemental statement of the case (SSOC). Where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VA has fulfilled the above requirements in the claims adjudicated herein for the appealed claims for service connection for hepatitis C and sleep apnea. A VCAA notice letter was sent in March 2010 addressing the hepatitis C claim, prior to the appealed May 2010 RO decision denying that claim. The notice included the risk factors for hepatitis C. A VCAA notice letter was sent in November 2010 addressing the sleep apnea claim, prior to the March 2011 RO decision denying that claim. The notice included how to substantiate a claim based on secondary service connection. The Board finds that these VCAA letters adequately addressed the evidence required to support both these claims. The letters further notified of the existence of certain presumptions by which service connection for a disability may be afforded a claimant. The VCAA letters informed the Veteran of the notice and duty-to-assist provisions of the VCAA, the bases of review, and the information and evidence necessary to substantiate the claims. He also was informed by these letters that it ultimately was his responsibility to see that pertinent evidence not in Federal possession was obtained. The Veteran was also afforded Dingess-type notice by these VCAA letters. The VCAA letters also requested that the Veteran advise of any VA and private medical sources of evidence pertinent to his claims and that he provide necessary authorization to obtain those records. They requested evidence and information about treatment after service in support of the claims. Based on information provided by the Veteran, post-service treatment records were obtained from VA and private sources. These records were associated with the claims file. The Veteran was informed appropriately of records obtained, including by the currently appealed rating decisions, and by an SOC in June 2011. He also was informed of records not obtained, the importance of obtaining all relevant records, and his responsibility to see that records are obtained in furtherance of his claims. In the absence of any report or indication of additional records not yet obtained relevant to the appealed claims, VA need not assist the Veteran in obtaining additional records and need not seek to obtain any for association with the claims file prior to the Board's adjudication of the currently appealed claims for a left knee disability and swollen neck glands. The Board notes that the Veteran reportedly has been in receipt of Social Security disability benefits, including for 10 years following an automobile accident in 1986. However, there is no indication in the record that the records underlying any such Social Security Administration disability determination would further the Veteran's claims for service connection for sleep apnea or hepatitis C, since those disorders are not indicated to be in any way related to the Veteran's disability for Social Security Administration disability purposes. See Golz v. Shinseki, 590 F.3d 1317, 1320 (Fed. Cir. 2010). The Veteran has also not indicated any receipt of care for his claimed disabilities for which he has not already provided authorization for records to be obtained, and for which records have not already been sought by the RO in the course of claim development, with obtained records associated with the claims file. The Veteran has reported that he has undergone no treatment for his hepatitis C infection beyond records obtained, and hence there are no such additional records to be obtained. The claim for service connection for sleep apnea is herein denied based on the absence of medical or scientific evidence supporting a link, based on causation or aggravation, between PTSD and the claimed condition. Hence, there is no reasonable possibility that additional records of treatment would further that claim. VA's duty to assist the Veteran by providing examinations when necessary has also adequately fulfilled. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board notes that VA must provide a medical examination or obtain medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. The Board does not find that a VA examination addressing the Veteran's claimed hepatitis C and etiology related to service is warranted in this case. A June 2000 private treatment record notes the Veteran's blood transfusion post service in 1986 as a potential source of infection. The Board rejects as lacking in credibility the Veteran's account of having been exposed to others soldiers' blood when helped rescue and attend to injured fellow soldiers aboard ship while he had scraped hands. As discussed below, the scraped hands and participation in manning hoses when his hands were allegedly scraped are not supported by service records and are indeed in conflict with the documentation, as contained within a service citation, of the Veteran's activities the night of the aircraft accident. Also as discussed below, the Veteran's self-reported histories of intravenous drug use are inconsistent in their chronology, rendering them lacking in credibility. Because the Board rejects the credibility of the Veteran's account of blood exposure in service, the Board finds no credible evidence to support a potential avenue of exposure to hepatitis C in service. The Board also finds that the June 2000 private medical report diagnosing hepatitis C and supporting a post-service blood transfusion as a potential avenue of infection, and subsequent records verifying the presence of hepatitis C, are all the medical evidence required in this case to support the Board's adjudication. Thus, absent credible evidence establishing that an event, injury, or disease occurred in service to support the claim, and because the Board finds that there is sufficient medical evidence on file to support the Board's decision on the claim, a VA examination addressing the question of a causal link to service is not warranted. 38 C.F.R. § 3.159(c)(4)(i); McLendon, 20 Vet. App. at 79. As discussed below, the Board finds the VA examination afforded the Veteran in February 2011 addressing the Veteran's sleep apnea claim and the March 2011 addendum to that examination opinion, taken together, adequate for the Board's adjudication of that claim. This examination and addendum were conducted or produced in conjunction with the Veteran's prior history, and they described the Veteran's sleep apnea syndrome and any medical or scientific relationship to PTSD, based on causation or aggravation, in sufficient detail so that the Board's evaluation herein is an informed one. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Because any relationship to the Veteran's PTSD was rejected by the VA examiner based on the absence of any medical or scientific basis to support causation or aggravation of sleep apnea by PTSD, past medical or other history specific to the Veteran's claim were not ultimately pertinent to these medical conclusions. The Board finds that the examinations, taken together with the balance of medical and non-medical evidence of record, provide sufficient detail and sufficient medical evidence and findings to allow for appropriate Board adjudication of the sleep apnea claim. 38 C.F.R. § 4.2 (2013); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board notes that the Veteran was afforded VA examinations and treatment records were obtained subsequent to the SOC in June 2011. However, these dealt with other current disabilities and not questions of etiology of claimed disabilities or causation or aggravation of sleep apnea by service-connected PTSD. Current diagnosis of hepatitis C and sleep apnea is not reasonably in dispute, and was not prior to the June 2011 SOC. Hence, to require further RO review of additional non-pertinent evidence prior to Board adjudication would amount to unnecessary expenditure of scarce VA resources as the evidence is essentially not pertinent to the claims. Additionally, the Veteran's authorized representative by a submitted April 2013 letter informed that the Veteran and his representative considered the evidence sufficient for the Board's adjudication of the claims, with the only additional argument then submitted in that letter. The representative expressly asked that a decision be made based on the written record contained in the claims file. In view of the foregoing, the Board finds that no further notice or assistance to the appellant is required to fulfill VA's duty to assist in the development of the currently appealed claims adjudicated herein. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. at 183. Neither the Veteran nor his representative has presented any avenues of evidentiary development which have a reasonable possibility of furthering the claims. 38 U.S.C.A. § 5103A (a)(2); 38 C.F.R. § 3.159. The Veteran has submitted lay statements in support of the claims. While he had requested a hearing before the Board hearing officer, he withdrew that request in a signed written statement received in April 2013. There is no indication that the Veteran desires a further opportunity to address his claims adjudicated herein. In view of the foregoing, the Board finds that all notification and development actions needed to render a decision on the Veteran's currently appealed claims for service connection for hepatitis C and sleep apnea have been accomplished. II. General Laws Governing Claims for Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. Disorders diagnosed after discharge may still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). To establish service connection for a disability, a claimant must submit evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus between the current disability and the in-service disease or injury. See Pond v. West, 12 Vet. App. 341, 346 (1999). However, service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis, when the claimed disability is due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310 (2013). While medical evidence may be required to address questions of diagnosis or causation specifically requiring medical expertise, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability which may reasonably be observed by laypersons. See 38 C.F.R. § 3.303(a). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a disability when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) ("in some cases, lay evidence will be competent and credible evidence of etiology"). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996). In this, as in any other case, it remains the duty of the Board as the fact finder to determine the relative credibility of the evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). The Federal Circuit has held that the Board is obligated to, and fully justified in, determining whether lay testimony is credible in and of itself, and that the Board may weigh the absence of contemporary medical evidence against lay statements. Buchanan, 451 F.3d at 1336-37. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in doing so, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998). The Board cannot make its own independent medical determination, and it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "it is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board has an obligation to provide reasons and bases supporting this decision, but there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). III. Claim for Service Connection for Hepatitis C The Veteran contends that he should be service connected for hepatitis C, based on evidence favoring his having contracted the disease in service when he came in contact with other soldiers' blood during an aircraft accident aboard ship. In a March 2010 statement in support of the claim, the Veteran alleged, "the night of the aircraft accident while manning fire hoses my hands became scratched up by the non-skid surface of the flight deck. I also helped move wounded and burned to stretches that night and came into contact with others blood." Service records document that the Veteran was aboard the aircraft carrier USS Nimitz on the night of May 25, 1981, when an aircraft crashed into the ship and fires ensued. A commendation the Veteran received for his actions that night is contained in the claims file, and specifies the scope of his participation. It states that the Veteran's role as part of the backup firefighting team consisted of "providing support to the frontline firefighting," including "providing equipment and supplies to the hose teams and stood ready to provide relief as necessary." The Veteran's "support to medical reaction and reclamation efforts" that night are also specified in the commendation: "he provided immediate first aid and transported injured shipmates to emergency medical stations." The Veteran's other participation that night was noted to include "dedicated long hours during and after the accident performing tedious yet vital administrative functions such as accurate accounting of personnel and assessment of equipment damage." Service records including this letter of commendation fail to support the Veteran's assertions of his scraping his hands while manning fire hoses to extinguish the fires aboard ship. The detailed nature of the service commendation the Veteran received, specifying the precise extent of his activities on the night of May 25, 1981, strongly supports the conclusion that if the Veteran had himself engaged in "manning the fire hoses" fighting the shipboard fires this would have been specified, rather than his specified participation "providing equipment and supplies to the hose teams" and 'standing ready' to provide relief. The citation thus informs that as a backup firefighter the Veteran was ready to directly participate in manning the hoses to fight the fire, but that he did not because he was not needed for this purpose. Also in his statement in support of claim in March 2010, the Veteran reported using hash, marijuana, and alcohol in service. He then reported not using cocaine until 1993, and reported that he then smoked cocaine. He added that his hepatitis C positive status was discovered when he donated blood in 1999, and he subsequently started to snort and inject cocaine in 2001, but that he always used clean needles. These March 2010 statements are somewhat contradicted by his own statements upon seeking VA psychiatric care in October 2010. As the Veteran informed at an initial VA psychiatric treatment interview in October 2010, he used "everything from 1999 to January 2009," including "IV cocaine and IV methamphetamines." His October 2010 statement introduces intravenous drug use from 1999 rather than 2001. The October 2010 statement by itself would thus still support the theory of hepatitis C infection by means other than intravenous drug use, since the Veteran was reportedly discovered in 1999 to have hepatitis C, and thus arguably still prior to his initiating intravenous drug use. However, the changed narrative, from use beginning in 2001 to use beginning in 1999, and the introduction of the previously unstated intravenous methamphetamines, informs that the Veteran's self-reported history of intravenous drug use is unreliable in its details including as to reported date of initiation of intravenous drug use. Additionally, the Veteran's report of not initiating intravenous drug use until after he was diagnosed with hepatitis C would be potentially motivated by secondary gain, since it would support other means of hepatitis C infection, in furtherance of his claim. Based on both the Veteran's demonstrated unreliability as a historian of his intravenous drug use and the potential motivation of secondary gain, the Board finds the Veteran's accounts of intravenous drug use history not to be credible. Post-service records also reflect that the Veteran received a blood transfusion following a severe automobile accident in 1986. The Veteran reported this in a June 2000 private treatment record, and he also acknowledged the blood transfusion in his March 2010 statement. The private treatment record in June 2000 documents a diagnosis of hepatitis C, and also then documents the report that the Veteran was told about a year earlier that he had hepatitis C. Private liver biopsy findings dated in March 2008 confirm the presence of chronic hepatitis, compatible with the diagnosed hepatitis C. The disease was then graded as stage zero, with no fibrosis and minimal macrovesicular steatosis. The Veteran's self-reported extensive drug use, including intravenous drug use, over several years, and his blood transfusion in 1986, present the greatest opportunities for hepatitis C infection. See Veterans Benefits Administration Training Letter 01-02 (Apr. 17, 2001) (setting forth the recognized risk factors of hepatitis C, including intravenous drug use and transfusion of blood before 1992). Based on the Veteran's contradicted statements-both as to his history of intravenous drug use and his history of participation in activities on the night of the in-service airplane crash aboard the USS Nimitz-render his uncorroborated statements of blood contact in the course of assisting in that aftermath of that airplane crash of essentially no credibility and hence of no weight in the present adjudication. Thus, the Board does not accept as supporting hepatitis C exposure in service the Veteran's account of coming in venous blood contact with injured soldiers' blood through scratched hands when assisting in fellow soldiers' rescue during the aftermath of the USS Nimitz airplane crash on the night of May 25, 1981. Because the Board finds no credibility in the Veteran's allegation of potential in-service exposure to hepatitis C, there is no credible evidence to support in-service exposure to hepatitis C. In contrast, the Board finds ample evidence of potential hepatitis C exposure post service through the blood transfusion in 1986 or the intravenous drug usage. Because the preponderance of the evidence favors a greater likelihood of the Veteran having become infected with hepatitis C in years following service, the preponderance of the evidence is against the Veteran having contracted hepatitis C in service. Because contracting hepatitis C in service is the only theory of entitlement for this claim, the preponderance of the evidence is against the claim for service connection for hepatitis C. 38 C.F.R. § 3.303. IV. Claim for Service Connection for Sleep Apnea as Secondary to PTSD The Veteran has contended that his service-connected PTSD has aggravated his sleep apnea. The Veteran, as a lay person, lacks the requisite medical expertise to address the distinctly medical question of whether PTSD caused or aggravated sleep apnea due to the complexity of such a matter. A VA medical opinion was obtained specifically to address this question, and the examining medical practitioner provided February and March of 2013 opinions that the Veteran's sleep apnea was not caused or aggravated by his PTSD. The examiner explained that there was no medical or scientific evidence to support such causation or aggravation. Thus, the medical opinion weighs against the Veteran's PTSD causing or aggravating his sleep apnea, and no competent evidence has been presented supporting such a link based on causation or aggravation. The Veteran did submit abstracts of journal articles addressing issues or findings of something described as sleep-disordered breathing, or SDB. However, these articles do not address a link between such SDB and the claimed sleep apnea. The abstracted articles rather raise questions of causal links between PTSD and disturbed sleep while pointing out that the direction of causation between the two is not clear. One submitted article found a higher prevalence of sleep apnea among veterans with PTSD, and thereby informed of the possibility of an association. Amir Sharafkhaneh, Nilgun Giray, et al, Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort, 28(11) SLEEP 1405-1511 (2005). Thus, the only article addressing a study looking at sleep apnea and PTSD only addressed the possibility of a causal or other association between the conditions. Concerning this, the Board notes that a "possible" connection or one based on "speculation" is too tenuous a basis on which to grant service connection. The reasonable doubt doctrine requires that there be a "substantial" doubt and "one within the range of probability as distinguished from pure speculation or remote possibility." 38 C.F.R. § 3.102. Based on the submitted articles suggesting such a possibility, the VA medical opinions were obtained, and as noted, these medical opinions were against PTSD causing or aggravating the Veteran's sleep apnea. The Board finds the February and March 2013 medical opinions to be adequate based on the examiner's review of relevant evidence and based on the opinions being supported by a rationale relying on the present state of medical knowledge. This rationale-that there is no basis in the medical or scientific knowledge to support the contended causation or aggravation-appears supported by the submitted scientific article and scientific abstracts, which themselves also noted absence of medical knowledge of a causal link between psychiatric disability and a sleep disorder characterized by breathing impairment. The Veteran also submitted statements from a fellow soldier and from a friend from childhood, variously addressing sleep difficulties in service, prior to service, and following service. However, these statements, as statements of lay observation, cannot serve to support the presence or absence of sleep apnea, which is a distinct medical condition requiring medical diagnosis based on medical studies, and not a condition, such as a visibly broken limb, susceptible to lay identification. Jandreau, 492 F.3d at 1377. With the only competent evidence presented directly addressing the question, in the form of the February and March of 2013 VA medical opinions, weighing against PTSD causing or aggravating sleep apnea, the weight of competent evidence is against any such link between service-connected PTSD and claimed sleep apnea. The weight of competent evidence also does not support sleep apnea having begun in service or otherwise being directly related to service, with no competent evidence presented to support this. The evidence of record informs of initial sleep apnea diagnosis many years following service. The preponderance of the evidence is thus against the claim for service connection for sleep apnea on both direct and secondary bases. 38 C.F.R. §§ 3.303, 3.310. V. Benefit of Doubt Because the preponderance of the evidence is against the claims the subject of this appeal, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. ORDER Service connection for hepatitis C is denied. Service connection for sleep apnea is denied. ____________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs