Citation Nr: 1311290 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 09-32 392 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected restrictive lung disease, hypertensive vascular disease and/or aortic insufficiency. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. R. Mullins, Counsel INTRODUCTION The Veteran had active service from October 1965 to August 1969, from January 1973 to March 1974 and from August 1981 to April 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, denying the claim of entitlement to service connection for sleep apnea. The Board notes that the RO issued a separate rating decision in January 2010 denying service connection for sleep apnea as secondary to the service-connected disability of restrictive lung disease. However, this rating decision was issued in error, as the issue of entitlement to service connection for sleep apnea was already on appeal to the Board. Generally, VA has a duty to consider and develop a claim under all theories of entitlement. See Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004); Robinson v. Peake, 21 Vet. App. 545, 552-53 (2008). The Veteran testified at a hearing before the undersigned Acting Veterans Law Judge (AVLJ) at the RO in Montgomery, Alabama in June 2011. A written transcript of this hearing has been prepared and incorporated into the evidence of record. The Board notes that additional evidence has been incorporated into the record since the last supplemental statement of the case (SSOC) in April 2010. However, in June 2011, VA received a waiver of RO consideration of the additional evidence. As such, a remand for consideration of this evidence by the Agency of Original Jurisdiction (AOJ) in the first instance is not necessary. (CONTINUED ON NEXT PAGE) FINDINGS OF FACT 1. The Veteran's obstructive sleep apnea did not manifest during, or as a result of, active military service. 2. The Veteran's obstructive sleep apnea was neither caused by nor aggravated by a service-connected disability, to include aortic insufficiency, hypertensive vascular disease, restrictive lung disease or arthritis of the lumbar spine. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable 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 notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Previously, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the failure to provide pre-adjudicative notice of any of the necessary duty to notify elements was presumed to create prejudicial error. Sanders v. Nicholson, 487 F.3d 881 (2007). VA was required to show that that the error did not affect the essential fairness of the adjudication, and that to make such a showing the VA had to demonstrate that the defect was cured by actual knowledge on the claimant's part or that a benefit could not have been awarded as a matter of law. Id. However, the United States Supreme Court (Supreme Court) held this framework to be inconsistent with the statutory requirement that the CAVC take "due account of the rule of prejudicial error" under 38 U.S.C.A. § 7261(b)(2). Shinseki v. Sanders, 556 U.S. 396 (2009). In reversing the Federal Circuit's decision, the Supreme Court held that the burden is on the claimant to show that prejudice resulted from the error, rather than on VA to rebut a presumed prejudice. Id. Letters sent to the Veteran in December 2007 and December 2009 addressed all notice elements listed under 3.159(b)(1) and the December 2007 letter was sent prior to the initial RO decision in this matter. The letters informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence as well as the criteria for establishing a disability rating and effective date of award. Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA obtained the Veteran's service treatment records. Also, the Veteran received a VA medical examination in December 2009, and VA has obtained these records as well as the records of the Veteran's outpatient treatment with VA. An expert medical opinion from a Veterans Health Administration (VHA) physician was also obtained in October 2012. This VHA examiner expressed multi-faceted opinions based upon a factual foundation provided by the Board. This examination report thoroughly analyzes and discussed the evidence and the rationale for the opinions expressed. Copies of the Veteran's private treatment records were also obtained and incorporated into the claims file. In Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the hearing in June 2011, the undersigned advised the Veteran of the types of evidence and/or information deemed necessary to substantiate his claim. The record reflects a discussion of the various theories of entitlement, the potential benefit of submitting a lay statement from his spouse, and the type of subject matter content in a medical opinion or medical treatise materials which may help to substantiate the claim. As such, the Board finds that it has fully complied with the Bryant requirements. Significantly, neither the Veteran nor his representative has identified any additional existing evidence that is necessary for fair adjudication of the claim that has not yet been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. 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. 183 (2002). Relevant Laws and Regulations Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In general, service connection requires a claimant to satisfy a three element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In some circumstances, certain chronic diseases listed at 38 C.F.R. § 3.309(a) may be presumed to have been incurred in service if manifest to a compensable degree within one year from discharge from service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 are also satisfied. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. § 3.309(b). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. However, the continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus.") In the case at hand, the Veteran's disease entity of obstructive sleep apnea is not among the list of chronic diseases listed within 38 C.F.R. § 3.309(a). Thus, the provisions of 38 C.F.R. §§ 3.303(b) and 3.303(a) do not apply in this case. Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Also, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. See 38 C.F.R. § 3.310(b); Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). A lay claimant is competent to provide testimony concerning factual matters of which he or she has firsthand knowledge (i.e., reporting something seen, sensed or experienced). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Under certain circumstances, lay statements may serve to support a benefits claim by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In Barr, the Court emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of the presence or absence of the claimed symptomatology. However, there are clearly limitations regarding the competence of a lay claimant to speak to certain matters, such as those involving medical diagnosis and etiology. See Jandreau, 492 F.3d at 1377, footnote 4 (Fed. Cir. 2007) (noting that a layperson is competent to describe a simple matter such as a broken leg but not competent to diagnose a form of cancer). VA has defined competent lay evidence as any evidence not requiring that the proponent have specialized education, training or experience. 38 C.F.R § 3.159(a)(1). Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a layperson. Id. Further, competent medical evidence is defined as evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions. 38 C.F.R § 3.159(a)(2). Although the Federal Rules of Evidence do not apply to veterans' jurisprudence, recourse to the Federal Rules of Evidence is appropriate, where the Rules assist in the articulation of the Board's reason. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997). As reflected in Fed.R.Evid 701, lay witness testimony is permissible in the form of opinions or inferences when (a) rationally based on the perception of the witness and (b) helpful to a clear understanding of the witness' testimony or the determination of a fact in issue. Otherwise, in matters involving scientific, technical or other specialized knowledge, Fed.R.Evid 702 requires that an opinion be provided by a witness qualified as an expert by knowledge, skill, experience, training or education. In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Notably, the benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. Pertinent Facts The Veteran contends that he is entitled to service connection for obstructive sleep apnea. He has argued that this condition manifested during military service. He has also argued that this condition was either caused by or permanently aggravated by a service-connected disability. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran's obstructive sleep apnea did not manifest during, or as a result of, active military service, nor was it caused by, or permanently aggravated by, a service-connected disability. As such, service connection for obstructive sleep apnea is not warranted. The Veteran's service treatment records do not reflect treatment for, or complaints of, sleep apnea or any related symptomatology during active military service. The Veteran's February 1988 separation examination report reflects no diagnosis of sleep apnea or associated symptomatology. The Veteran also denied having frequent trouble sleeping in his report of medical history associated with this examination and he described his health as "[f]air to good." Post-service medical records also fail to demonstrate that the Veteran's obstructive sleep apnea manifested during, or as a result of, active military service. A November 2006 sleep center report reflects that the Veteran was diagnosed with obstructive sleep apnea. It was noted that during the first 103.5 minutes of sleep, the Veteran experienced 129 disordered breathing events, yielding a respiratory disturbance index of 74.8 events per hour. The Veteran was set up with a CPAP machine to treat this condition. A December 2006 private sleep center report reflects a diagnosis of obstructive sleep apnea. It was noted that a split-night study was performed in November 2006 reflecting 74.8 events per hour. A January 2008 sleep center report reflects that the Veteran retired from his job in December. A diagnosis of obstructive sleep apnea syndrome was again assigned. It was noted that the Veteran could tell a significant difference in the way he felt during the day after using his CPAP machine and the importance of weight loss was discussed with the Veteran. The record contains an undated statement from a private physician with the initials D.G. Dr. G noted that the Veteran was under his care for treatment of severe obstructive sleep apnea. It was noted that this diagnosis was based on a study performed in 2006. The Veteran reported that he had been struggling with daytime sleepiness and snoring for many years prior to this study and noted that his snoring dated as far back as his teenage years. Dr. G also noted that the Veteran had a deviated septum that likely contributed to his obstructive sleep apnea. Dr. G also indicated that the Veteran had hypertension during military service, and that hypertension is frequently caused by obstructive sleep apnea. The Veteran also gained 25 pounds during military service, which is a major cause of obstructive sleep apnea. As such, Dr. G concluded that it was likely that his sleep apnea was present during military service. However, Dr. G could not give a medical opinion about whether the Veteran did or did not develop obstructive sleep apnea before leaving active duty. Medical data was not available at this time from which he could determine how long it takes a severe case of obstructive sleep apnea to develop. However, Dr. G did note that obstructive sleep apnea does develop slowly over a long period of time. The record also contains an August 2007 medical report from a private physician with the initials T.F. Dr. F noted that the Veteran had been having episodes of tachypalpitations. Dr. F indicated that it was very pertinent to note that the Veteran had been diagnosed with sleep apnea since he was last seen by Dr. F. Dr. F discussed with the Veteran the correlation between untreated sleep apnea and cardiac dysrhythmias. Dr. F specifically concluded that he suspected that the Veteran was having brief atrial dysrhythmias most likely secondary to untreated sleep apnea. Dr. F also noted in October 2007 that the Veteran's hypertension was certainly significant in part due to his obstructive sleep apnea. The Veteran was afforded a VA examination for miscellaneous respiratory diseases in January 2008. It was noted that the Veteran was diagnosed with sleep apnea in December 2006 after years of snoring, restless sleep and daytime fatigue. The examiner opined that obstructive sleep apnea was not caused by or a result of hypertension or aortic valve disease. It was explained that sleep apnea was known to be a disorder related to upper airway obstruction. There was no evidence in the medical literature supporting the contention that either hypertension or valvular heart disease could be a cause of obstructive sleep apnea. The record also contains an April 2008 statement from a physician with the initials A.D.T. According to Dr. T, an otolaryngology evaluation revealed the Veteran to have a pronounced rightward septal deviation. There was no history of a past nasal trauma and this was confirmed by a computed tomography (CT) scan. Dr. T opined that the Veteran's nasal septal deviation was long-standing and had been present since at least teenage years. Dr. T also concluded that this contributed to his nasal stuffiness, sleep apnea and difficulty using a CPAP machine. The Veteran was afforded a VA examination in December 2009. It was noted that the Veteran was diagnosed with obstructive sleep apnea in November 2006. The Veteran also reported that he had been snoring since his early 30s. It was also noted that the Veteran used to work in a career where he worked from 11 PM to 7 AM and that he would have problems with sleepiness driving home. The examiner reviewed the claims file and did not note any complaints of hypersomnolence during his active military service. The examiner diagnosed the Veteran with a deviated septum and obstructive sleep apnea. He was also noted to be suffering from obstructive lung disease that was service-connected. The examiner concluded that the Veteran's obstructive sleep apnea was not caused by or worsened by his service-connected lung disease. The examiner reviewed the medical literature and did not find any causative relationship between obstructive sleep apnea and obstructive lung disease. The examiner acknowledged that the use of the term "obstructive" in both conditions probably sounded as though they might be related to one another. However, it actually refers to a different portion of the airway passages and it was not causative or related to sleep apnea. In October 2012, VA received a medical opinion from a staff physician with the Pulmonary Service at the Columbia, South Carolina VA Medical Center (VAMC). The physician opined that it was less likely than not that the Veteran's sleep apnea was caused by his aortic insufficiency. The physician explained that there were no scientifically sound studies linking sleep apnea as causing aortic insufficiency or vice versa. There were also no recommendations to look specifically for valvular heart disease in patients with sleep apnea. The physician further opined that it was less likely than not that the Veteran's sleep apnea was "aggravated at all" by his mild aortic insufficiency. The physician explained that based on his knowledge with his Board certification in internal medicine, pulmonary medicine, critical care and sleep medicine, as well as a review of the medical literature, he was unaware of mild aortic insufficiency aggravating sleep apnea, especially since it appeared that the Veteran had preserved left-sided heart function and had denied PND or orthopnea in most medical records. The physician noted that an association with worsening sleep apnea might exist if the aortic insufficiency was more severe, leading to left-sided heart failure and refractory pulmonary edema. However, this was not the case. The physician further opined that the Veteran's sleep apnea was less likely than not caused by his service-connected hypertensive vascular disease. The physician explained that hypertension did not cause sleep apnea. It was noted that sleep apnea may be associated with the development of hypertension, but sleep apnea was more associated with treatment resistant hypertension which the Veteran does not have. The physician acknowledged that the Veteran and his wife reported snoring since 1968. However, the Veteran had other reasons for this, such as a deviated septum and allergies which were as likely or more to cause snoring in a young man. Snoring alone is common in up to half of males between 30 and 60, and sleep apnea is more common in older males. There was no mention in the records of sleep problems during active service and somnolence was not reported until 1992 and is commonly seen in night shift workers due to the natural circadian sleep drive. The physician further opined that it was less likely than not that the Veteran's sleep apnea was aggravated by his hypertension. The physician explained that hypertension does not worsen obstructive sleep apnea. The physician further opined that it was less likely than not that the Veteran's sleep apnea was caused by his restrictive lung disease. The examiner explained that the etiology of the Veteran's restrictive lung disease was not clear. It was further noted that restriction may be caused by obesity which may worsen sleep apnea. However, the physician could not say in this case that his restriction was due to his weight without resorting to speculation. Likewise, the examiner opined that it was less likely than not that the Veteran's sleep apnea was aggravated by his service-connected restrictive lung disease. The physician explained that there was not enough information to conclude that restrictive lung disease was aggravating sleep apnea. The physician further opined that it was less likely than not that the Veteran's sleep apnea was caused by or aggravated by his service-connected arthritis of the lumbar spine. There was no medical evidence to the physician's knowledge or from the Veteran's records regarding arthritis causing, or aggravating, sleep apnea. Finally, the physician opined that it was less likely than not that the Veteran's sleep apnea first manifested during a period of active service. The physician explained that the Veteran had other reasons as likely to cause primary snoring, including a deviated septum and allergy symptoms. The deviated septum was noted to be most likely caused by congenital formation or some type of mild trauma. It was not likely that the conditioning performed in service caused "the walls of [the Veteran's] airway to weaken." Also, primary snoring is more common than sleep apnea in young non-obese males. There were also no complaints in the medical record of any other symptoms strongly associated with sleep apnea during military service. Even the report of somnolence in 1992 was felt to be more likely associated with shift work and his altered circadian sleep drives. The Veteran's wife also did not report witnessing apneas until after his active duty was over. Finally, the fact that the Veteran was diagnosed with hypertension during military service did not lead the physician to automatically assume that sleep apnea also developed during active duty, especially since hypertension was relatively easy to control and hypertension is so common in general. Analysis The preponderance of the above evidence demonstrates that the Veteran is not entitled to service connection for obstructive sleep apnea, to include as secondary to any service-connected disability. Initially, the Board notes that the Veteran's service treatment records fail to reflect a diagnosis of sleep apnea or treatment for any related symptomatology. In fact, the first diagnosis of sleep apnea is from November 2006 - approximately 18 years after the Veteran's separation from active duty. When considering whether or not to grant a claim for service connection, the Board may take into consideration the passage of a lengthy period of time in which the Veteran obtain treatment for disorder at issue. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In the present case, the absence of any treatment for sleep apnea for nearly 18 years after military service tends to weigh against a finding of inservice onset. The Board recognizes that the Veteran and his wife have alleged that he snored since military service, and began experiencing daytime tiredness several years after service. In a July 2011 statement, the Veteran's wife reported that the Veteran had been a snorer ever since their marriage in 1968. The Veteran also testified that his snoring began during active military service. This is certainly something the Veteran and his wife are competent to provide testimony about. The Board does not doubt the credibility of this evidence, and specifically instructed the VHA examiner to accept the symptomatology descriptions by the Veteran and his spouse as true. However, the fact that the Veteran had snoring symptoms in service does not, per se, establish the onset of obstructive sleep apnea in service. As explained by the October 2012 physician, snoring is common in about 50 percent of young males, and the Veteran's 3rd shift job had the potential for disrupting his natural circadian sleep drive. The Veteran had other reasons for snoring since 1968, including nonservice-connected deviated septum and allergies. Overall, the Board finds no persuasive evidence linking the Veteran's sleep apnea to military service or to a service-connected disability. According to the January 2008 VA examiner, obstructive sleep apnea was not caused by or a result of, hypertension or aortic valve disease. Sleep apnea was related to upper airway obstruction and there was no evidence in the medical literature supporting the contention that either hypertension or valvular heart disease could be a cause of obstructive sleep apnea. The December 2009 VA examiner also concluded that the Veteran's obstructive sleep apnea was not caused by or worsened by his service-connected lung disease. It was again noted that there was nothing in the literature to support such a conclusion and that a lung disease and obstructive sleep apnea affect different portions of the airway passages. The October 2012 VA physician also reviewed the evidence of record and relevant medical literature, and concluded that it was less likely than not that the Veteran's obstructive sleep apnea was caused by, or aggravated by, a service-connected disability. There was nothing in the literature to suggest that aortic insufficiency, hypertensive vascular disease, restrictive lung disease or arthritis of the lumbar spine. Finally, the physician opined that it was less likely than not that sleep apnea manifested during military service, as there were no complaints during service of associated symptomatology and the Veteran's first report of somnolence in 1992 was more likely associated with shift work and his altered circadian sleep drives. On the other hand, the Veteran believes his sleep apnea is either related to military service, or, to a service-connected disability. In a July 2008 statement, he indicated that he did not submit additional evidence because he thought "it was so well known that sleep apnea was so closely connected to both hypertension and heart disease." The Veteran's allegations and theory clearly have some probative value, and it is possible that some of his information has been relayed from his treating physicians. See generally Jandreau, 492 F.3d 1372 (Fed. Cir. 2007). However, the Board finds that the opinion of the VHA physician greatly outweighs the opinion offered by the Veteran and his spouse, as this specialist has greater training and expertise to speak to the medical issue of diagnosis and etiology of obstructive sleep apnea. The VHA opinion also outweighs any evidentiary value of information relayed by the Veteran from his treating physician, as the Board does not have the benefit of review of the rationale underlying the opinion. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that a medical opinion does not hold probative value when it fails to provide sufficient detail and rationale to allow the Board to make a fully informed evaluation of the disability). The Veteran has also submitted numerous private medical records which he asserts support his claim. This evidence suggests that obstructive sleep apnea has the potential to cause tachypalpitations or aggravate hypertension, but does not describe a similar reverse correlation. In any event, the probative weight of this evidence is greatly outweighed by the opinion of the VHA examiner, who has offered an opinion which provides a clear and precise rationale for the conclusions reached. The Board notes that the undated statement of Dr. G does suggest that it was likely that sleep apnea was present during military service. It is not entirely clear what evidence was relied upon in making this determination. Dr. G noted that the Veteran reported snoring back to his teenage years and that he gained weight during military service. However, Dr. G does not appear to have considered the fact that the Veteran himself did not report somnolence until 1994 when he began working the late shift. Nonetheless, Dr. G indicated that he was unable to offer an opinion as to whether the Veteran's currently diagnosed obstructive sleep apnea manifested during military service. All he could state was that this condition did develop slowly over a long period of time. 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 so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). But, we are mindful that the Board cannot make our own independent medical determinations, and that the Board must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans, 12 Vet. App. at 30; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. Dr. G simply stated that it was likely that the Veteran had sleep apnea during service due to his deviated septum and the fact that he gained weight. Dr. G did not reconcile this statement with the fact that the Veteran has specifically denied symptomatology such as somnolence until beginning a night job in 1992. The October 2012 VA physician, however, reviewed the medical literature of record, accepted as true the lay statements of record and formulated an opinion discussing why it was less likely than not that the Veteran's sleep apnea first manifested during a period of active service. In light of the VA physician's extensive discussion of relevant evidence and medical research, the Board finds this opinion to be more probative than that of Dr. G. Finally, the Board has considered the numerous internet articles regarding sleep apnea submitted by the Veteran in support of his claim. These articles define what sleep apnea is and note that obstructive sleep apnea could aid in the development of heart problems. The probative weight of these materials is greatly outweighed by the opinion of the VHA examiner, who has offered an opinion based upon the specific facts of this case rather than the medical treatise information which does not address the specific facts of this case. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability, must be denied. ORDER The claim of entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected restrictive lung disease, hypertensive vascular disease and/or aortic insufficiency, is denied. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs