Citation Nr: 1313580 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 09-23 147A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for sleep apnea, including as due to service-connected hypothyroidism secondary to Graves' disease. ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from February 1972 to November 1992. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana, that, in pertinent part, granted service connection for Graves' disease that was assigned an initial 10 percent disability rating, and denied service connection for sleep apnea. Then, in an August 2009 rating decision, the RO found that a 30 percent rating for hypothyroidism secondary to Graves' disease was warranted for the entire appeal period. In a September 2012 decision, the Board granted a 60 percent rating for hypothyroidism secondary to Graves' disease. At that time, the Board remanded the Veteran's claim for service connection for sleep apnea to the RO for further evidentiary development. FINDING OF FACT The evidence of record preponderates against a finding that obstructive sleep apnea (OSA) had its onset or is otherwise related to the Veteran's military service and is not due to service-connected hypothyroidism. CONCLUSION OF LAW The criteria for service connection for sleep apnea including as due to service-connected hypothyroidism have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants 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 claimant 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 claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the 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. VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in August 2008 and February 2009 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The August 2008 letter provided notice as to how VA assigns an appropriate disability rating or effective date, curing any timing defect. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of her claim. This duty includes assisting her 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. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence regarding the claim for service connection for sleep apnea. The Veteran was afforded a VA examination in May 2009 and the examination report, along with a November 2009 Addendum, is of record. As noted above, in September 2012, the Board remanded the Veteran's case to the RO for further development that included obtaining recent VA medical records and scheduling her for a VA examination. There has been substantial compliance with the Board's 2012 remand as she was scheduled for VA examination in November 2012 and VA medical records, dated from September 2005 to October 2012, were obtained. The Board finds that the November 2012 examination report is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, examined the Veteran, provided clinical findings and diagnoses, and offered an etiological opinion with rationale from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326 (2012). The November 2012 VA examination report makes up for the deficiencies in the May 2009 VA examination report with the November 2009 Addendum. 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). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA treatment and examination. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant 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). II. Factual Background and Legal Analysis The Board notes that it has thoroughly reviewed the record in conjunction with this case that includes the Veteran's service treatment records, VA and non-VA medical records and examination reports, dated from 1993 to 2012, and the Veteran's written statements in support of her claim. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Under 38 U.S.C.A. §§ 1110 and 1131; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (to the effect that the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Nevertheless, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, case law has established that lay evidence can be competent and sufficient to establish a diagnosis of a condition 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 professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). To establish a right to compensation for a present disability, a veteran must show: "(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" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. In addition, secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). With regard to the matter of establishing service connection for a disability on a secondary basis, the United States Court of Appeals for Veterans Claims (court) has held that there must be evidence sufficent to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b). With regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). A service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of respiratory pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In written statements in support of her claim, the Veteran asserts that she has sleep apnea due to military service or, alternatively, due to her service-connected hypothyroidism secondary to Grave's disease. In June 2008 written statements, she stated that VA recently diagnosed her with OSA but she had the same symtoms in service, although OSA was never noted, just fatigue. She maintained that her service records document her complaints of chest pains, tiredness, and constant sleepiness that was unchanged. She was now diagnosed with sleep apnea and she believed that was likely the cause of her symptoms throughout the years. In an April 2009 statement, she asserted that, throughout her military career, she experienced shortness of breath, sleep problems, and snoring, but never associated it with a sleep disorder. Upon review of the evidence of record, and after considering the laws and regulations applicable to the Veteran's claim, the Board finds that service connection is not warranted. Service treatment records do not refer to diagnosis of, or treatment for, sleep apnea. The records describe the Veteran's repeated complaints of chest pain and dizziness. A March 7, 1985, clinical record includes the Veteran's complaint of intermittent chest pain for the past three years assessed as possible high blood pressure. On Reports of Medical History completed during service examinations in February 1986 and July 1987, she denied having frequent trouble sleeping but endorsed shortness of breath and chest pain. A respiratory abnormality was not noted on either examination. A March 27, 1989 clinical record reflects that the Veteran had chest pressure that woke her up gasping for breath. In April 1989, she complained of chest pain and drowsiness. On a Report of Medical History completed in May 1989 during a periodic service examination, she denied having frequent trouble sleeping and indicated that she had shortness of breath, pain or pressure in her chest, and palpitation or pounding heart. A respiratory abnormality was not noted on examination at that time. In October 1989, the Veteran was referred for a cardiology evaluation with myalgic-type chest pain. Chest x-rays were normal in 1988 and 1989. The Veteran was seen on November 29, 1989, with a history of atypical chest pain. It was noted that she had been first examined for chest pain in early 1989 and had severe chest pain in March 1989. She initially had left arm aching that lasted seconds. In June 1990, the Veteran was evaluated for dizziness and tiredness. In August 1992, the Veteran complained again of intermittent atypical chest pain for many years. A separation examination report is not of record. Post service, VA and non-VA medical records include February 1993 and December 1998 VA examination reports that do not describe complaints of sleep problems or a diagnosis of OSA. The February 1993 VA examination report shows that the Veteran had hypertension and chest pain of unknown origins. February 2004 VA medical records reveal that the Veteran was still tired and gave some symtoms of OSA with snoring. She did not feel rested and had daytime somnolence. The assessment included daytime somnolence. The examiner noted that the Veteran did not fit the typical OSA body habitus but did awake frequently at night per her husband's account and a sleep study was to be considered. A sleep study was evidently performed for VA in July 2004 at Indiana University due to the Veteran's report of snoring, apnea, sleepiness, insomnia and excessive daytime somnolence and headaches. Results of the study were apparently negative for OSA, as discussed infra. A September 20, 2005, VA otolaryngology record shows that the Veteran was evaluated for chronic fatigue with daytime sleepiness and excessive snoring for the past three to four years. The assessment was intrinsic sleep disorder and she was advised to see a sleep specialist. The examiner noted that the 2004 sleep study was scanned into the Veteran's medical records (although the Board is unable to locate it among her records). A November 2005 VA medical record indicates that the Veteran had symtoms of sleep apnea. According to a January 5, 2006, VA primary care record, the Veteran still complained of fatigue and tiredness. Her active medical problems included sleep disorders. It was noted that she was scheduled for a sleep study and that a previous test had been negative for sleep apnea. In March 2006, VA records indicate that the Veteran, who had gained 15 pounds, was scheduled for a repeated sleep study with titration if she qualified, although it appears that she did not show for her scheduled appointment. A November 2007 VA medical record reflects the Veteran's report that she had two previous sleep studies that were negative for sleep apnea. An April 2008 private sleep study report shows that the Veteran underwent prior sleep studies and was diagnosed with intrinsic sleep disorder, not otherwise specified. The report reflects an impression of obstructive sleep apnea. In May 2009, the Veteran underwent VA examination to determine if she had sleep apnea due to her service-connected hypothyroidism. The examiner reviewed the Veteran's medical records and performed a clinical evaluation. The Veteran gave a history of apnea that started in 1988 and progressively worsened. The clinical impression was obstructive sleep apnea. As to the etiology of the Veteran's OSA, the VA examiner was unable to resolve the issue without resorting to speculation. She stated that the literature indicates that several factors may be risk factors for sleep apnea. The Veteran's risk factors for apnea included overweight/obesity, aging, being postmenopausal, and hypothyroidism (secondary to overcorrection of Grave's disease). The VA examiner noted that the literature indicated that individuals who suffered from hypothyroidism may have a decrease in respiratory drive that may lead to OSA. The examiner found that the cause of the Veteran's OSA was most likely multifactorial in nature. Thus, the examiner was unable to resolve the issue without resort to mere speculation. But see Jones v. Shinseki, 23 Vet. App. 382 (2010) (when a medical examiner states no conclusion as to etiology or diagnosis can be reached without resorting to speculation, it must be clear, from either the examiner's statements or the decision of the Board that the examiner has considered "all procurable and assembled data," by obtaining all tests and records that might reasonably illuminate the medical analysis; when the record leaves the issue in doubt, it is the Board's duty to remand for further development). A later-dated May 29, 2009, VA Sleep Study Specialist note includes the examiner's opinion that the Veteran did not actually have sleep apnea. This examiner stated that he reviewed the Veteran's sleep studies from June 2004 and 2006 and found that they did not reflect a diagnosis of sleep apnea. It was noted that the Veteran underwent a titration study "presumably for sleep apnea," but that the diagnosis was not confirmed. An October 21, 2009 VA primary progress note shows that OSA was among the Veteran's active medical problems. Other October 2009 medical records reveal that the Veteran was provided with additional equipment for her CPAP machine. The records do not include a negative opinion regarding a diagnosis of OSA. A November 2009 Addendum to the May 2009 VA examination report reflects that a physician opined that the Veteran did not receive a diagnosis of obstructive sleep apnea. The examiner noted that a VA sleep medicine note from October 21, 2009 indicated that there was no sleep apnea present. A March 2010 VA medical record includes an impression of OSA for which the Veteran used a CPAP issued by the sleep medicine clinic. Pursuant to the Board's September 2012 remand, in November 2012, the Veteran underwent VA examination. The examiner reviewed the Veteran's medical records and performed a clinical evaluation. The examiner concluded that the Veteran had a diagnosis of obstructive sleep apnea. The VA examiner explained that there were "some confusing sleep study results in the past" but the last sleep study conducted in April 2008 by a private physician showed OSA. The examiner also noted that the Veteran was aggressively treated for OSA with CPAP by her VA physicians. On current examination, the Veteran reported an approximately 20 percent overall improvement in her sleeping with the ongoing use of CPAP. The VA examiner acknowledged that the Veteran "likely has some other contributing sleep problems, including periodic limb disorder and poor sleep hygiene, but this fact doesn't negate the effects of her OSA." The VA examiner disagreed with the medical opinion rendered in 2009 stating that the Veteran did not have OSA. The VA examiner noted that sleep studies performed on June 25, 2004 and March 13, 2006 showed primary snoring disorder and intrinsic sleep disorder, not otherwise specified. OSA was not definitively diagnosed until 2008. In the VA examiner's opinion, it was not at least as likely as not that the Veteran's OSA was caused by hypothyroidism. The examiner noted that the Veteran had strong risk factors for OSA, such as being overweight. Other relevant risk factors were symptoms of metabolic syndrome, middle/advanced age, postmenopausal status, and the fact that she is African American (an ethnic group that has the highest incident of OSA). The examiner remarked that the Veteran's OSA was not definitively diagnosed until 2009, while her hypothyroidism (after Grave's treatment) began in approximately July 2001 (when she started taking synthroid) after she was treated with radioactive iodine therapy in April 2001. The examiner observed that there was an eight year span between these diagnoses that did not suggest a causal relationship. The VA examiner also stated that, per medical records, the Veteran was placed on synthroid and was on the same dose since 2001 with very stable TSH levels. Per review of medical literature, the examiner noted that "hypothyroidism has been associated with causing OSA in cases where the hypothyroidism is more severe." The Veteran's hypothyroidism was anticipated (post Grave's treatment), treated promptly, was stable, and did not require adjustments. The VA examiner indicated that "[t]his suggests mild, stable hypothyroidism which would be less likely to cause OSA per medical literature." In the VA examiner's opinion, it was less likely than not that the Veteran's OSA was aggravated beyond natural progression due to her service-connected hypothyroidism. The examiner commented that the timing of the onset of the OSA and the hypothyroidism (as discussed above) did not suggest aggravation beyond natural progression, nor did the stability of her hypothyroidism over the years. According to the VA examiner, the Veteran's OSA symptoms remained fairly consistent since being diagnosed with no evidence of aggravation beyond natural progression in her medical records. She reported up to a 20 percent improvement in her sleeping with CPAP treatment, though she continued to be quite fatigued (that symptom was likely multifactorial). Again, the medical records reflect conflicting opinions as to whether the Veteran currently has OSA. Sleep studies in 2004 and 2006 reportedly did not diagnose OSA but, the April 2008 private study clearly did. Although the May 2009 VA examiner diagnosed OSA, a May 2009 VA clinician concluded that there was no OSA as did the November 2009 VA examiner, but the March 2010 VA sleep medicine record includes a diagnosis of OSA. Furthermore, the November 2012 VA examiner similarly concluded that the Veteran had OSA. The Board concludes that the evidence shows that the Veteran currently has obstructive sleep apnea. Here, the service treatment records do not provide evidence of a chronic OSA disorder in service. The Veteran had no treatment for complaints of sleep apnea. When she was evaluated during periodic service examinations in 1986, 1987, and 1989, no problems with sleep were identified and she denied poor sleep in reports of medical history. The first documented evidence of any type of sleep problem after service is from the VA records dated in 2004, over 12 years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (to the effect that a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming the Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). In short, no medical opinion or other medical evidence relating the Veteran's OSA disorder to service or any incident of service has been presented. The only probative opinion of record is that of the November 2012 VA examiner, who concluded that the Veteran had OSA that was less likely than not related to her service-connected hypothyroidism. According to the VA examiner, the Veteran had strong risk factors for OSA, such as overweight, symtoms of metabolic syndrome, middle/advanced age, postmenopausal status, and the fact that she is African American (an ethnic group that had the highest incident of OSA). Also, the Veteran's OSA was not definitively diagnosed until 2009 while her hypothyroidism (after Grave's treatment) began in approximately July 2001 (when she started taking synthroid) after she was treated with radioactive iodine therapy in April 2001. There was an eight year span between these diagnoses that did not suggest a causal relationship. The examiner commented that the Veteran's hypothyroidism was anticipated (post Grave's treatment), treated promptly, was stable, and did not require adjustments. The VA examiner indicated that "[t]his suggests mild, stable hypothyroidism which would be less likely to cause OSA per medical literature." The VA examiner opined that it was less likely than not that the Veteran's OSA was aggravated beyond natural progression due to her service-connected hypothyroidism. The examiner commented that the timing of the onset of the OSA and the hypothyroidism (as discussed above) did not suggest aggravation beyond natural progression, nor did the stability of her hypothyroidism over the years. According to the VA examiner, the Veteran's OSA symtoms remained fairly consistent since being diagnosed with no evidence of aggravation beyond natural progression in her medical records. The VA physician provided a clear rationale to support that opinion. There is no competent evidence to contradict this opinion. In so finding, the Board has considered the Veteran's contention that a relationship exists between her current OSA and military service including her service-connected hypothyroidism. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the United States Court of Appeals for Veterans Claims (Court), emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. 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 lay person). The Veteran is competent to describe her observable symptoms, such as sleepiness. However, she is not competent to make a statement of causation that is a medical determination. Barr v. Nicholson, 21 Vet. App. at 303; Buchanan v. Nicholson, 451 F.3d at 1331. To the extent she is claiming that sleep problems have persisted since service, this is inconsistent with the overall record, which reflects that her sleep symptomatology manifested after service. The Board has considered the Veteran's statements as to her incurrence during service, in light of her service treatment records, post-service medical evidence, and the November 2012 medical opinion. The Board finds that the objective medical evidence of record is most persuasive and of more probative value than the appellant's assertions. The record fails to reflect that the Veteran was treated on even one occasion for sleep difficulty during military service. The post service records show that OSA was diagnosed in 2008, more than 16 years after her discharge from service. The gap of time between military service and the first post-service medical evidence of OSA is, in itself, significant, and weighs against the appellant's claim. See Maxson v. Gober, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. at 356. The Board recognizes that the absence of documented post-service treatment cannot, by itself, invalidate the Veteran's claims of continuous symptomatology. However, to the extent that the Veteran is claiming continuity of sleep symptoms since service, she is not a reliable historian. She made no mention of sleep problems during her 1986, 1987, and 1989 periodic service examinations and examination of her respiratory system at those times was normal. She has not explained why she failed to mention pertinent difficulty when examined pursuant to service requirements. Additionally, she did not report having sleep problems when examined by VA in February 1993, just after her discharge from active service, or in December 1998. In September 2005, a VA clinician reported that the Veteran gave a history of excessive snoring for three to four years but, in April 2009, she reported always having snoring and sleep problems in service that she never associated with a sleep disorder. The Board does not find that there is credible evidence of continuity of symptomatology present in this case. Moreover, while the Veteran is competent to state that she experienced sleep problems in service, she is not competent to state that she has OSA or another respiratory disease. The internal pathology of OSA is not readily recognizable by a layman, such as varicose veins or acne. See Jandreau v. Nicholson. Even medical professionals rely on sleep studies and other diagnostic tools to diagnose OSA. Further, the November 2012 VA examiner, who reviewed the Veteran's in-service treatment records and reviewed her post service medical records, concluded that she had OSA that was not due to service-connected hypothyroidism. The Veteran's contentions are outweighed by the medical evidence and opinion of the November 2012 VA examiner that reflects that her OSA was less likely as not related to her service-connected hypothyroidism. The record also contains medical information from the Internet and the American Journal of Respiratory and Critical Care Medicine submitted by the Veteran in April 2009 in support of her claim that generally describes the relationship between primary sleep-hypopnea syndrome (OSA) and hypothyroidism. The journal article indicates that they have many signs and symtoms in common and that the overlap in clinical presentation, and the sleep-disordered breathing that can accompany hypothyroidism, create a significant risk of misdiagnosis of sleep apnea among patients referred to sleep clinic who have undiagnosed hypothyroidism. The above documents contain no specific findings pertaining to this Veteran's manifestation of OSA. As a lay person, relying on a generic medical treatise, the Veteran is not qualified to render a medical opinion as to the etiology of the cause of her claimed OSA. See Wallin v. West, 11 Vet. App. at 514 (holding that treatise evidence cannot simply provide speculative generic statements not relevant to the veteran's claim," but, "standing alone," must include "generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion" (citing Sacks v. West, 11 Vet. App. 314, 317 (1998))); see also Stadin v. Brown, 8 Vet. App. 280, 284 (1995). The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). In the present case, the medical literature submitted by the Veteran was not accompanied by the opinion of any medical expert. In fact, the Veteran has submitted not even one medical opinion to support her claim that she has OSA due to military service or to service-connected hypothyroidism. Furthermore, based on the analysis above, the competent medical evidence of record suggests that she does not currently have an OSA disorder that is at least as likely as not related to her active military service including service-connected hypothyroidism. Here, the only probative medical opinion of record is against the Veteran's claim. Therefore, while the Board has considered the medical literature, it is not sufficient to outweigh the opinion of the November 2012 VA examiner. In sum, the Board is left with no documented complaints of sleep problems in service, no documented complaints or findings of a diagnosed OSA disorder after service until 2008, and a VA medical opinion to the effect that the Veteran's diagnosed OSA was not caused or aggravated by service-connected hypothyroidism. The questions involved regarding causation are medical in nature. As discussed above, the medical opinion of the 2012 VA examiner (based on a review of the claims file and with knowledge of the Veteran's in-service duties and in-service complaints) was negative. In sum, a clear preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for sleep apnea, including as due to service-connected hypothyroidism secondary to Graves' disease, and her claim must be denied. The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). ORDER Service connection for sleep apnea including as due to service-connected hypothyroidism secondary to Graves' disease is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs