Citation Nr: 1334450 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 08-04 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, to include as due to an undiagnosed illness. 2. Entitlement to service connection for a sleep disorder, to include as due to undiagnosed illness and as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran had active service from July 1989 to March 1993. This matter comes before the Board of Veteran's Appeals (Board) on appeal from January 2007 and September 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In April 2012 and March 2013 the Board remanded this case for further development. The issue of entitlement to service connection for sinusitis/allergic rhinitis has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See Statement in Support of Claim, August 2013. Therefore, the Board does not have jurisdiction over it, and it referred to the AOJ for appropriate action. FINDINGS OF FACT 1. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a gastrointestinal disability causally related to, or aggravated by, active service or a service-connected disability. 2. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a sleep disorder causally related to, or aggravated by, active service or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a gastrointestinal disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1117, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317 (2013). 2. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1117, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Appropriate notice was provided in May 2007 and July 2007. In addition, in regard to the Veteran's claim of entitlement to service connection for a sleep disorder, to include as due to undiagnosed illness and as secondary to service-connected PTSD, the Veteran has demonstrated actual knowledge of the requirements for secondary service connection. See Statement in Support of Claim, November 2012. As such, adequate notice has been provided to the Veteran. The duty to assist has also been met and appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records. The appellant was afforded VA medical examinations in June 2007, April 2009, and July 2012, and a VA medical opinion was obtained in July 2013. The claims were remanded in April 2012 for attempts to obtain complete service personnel records, outstanding VA treatment records dated subsequent to August 2010, and examination for etiology of gastrointestinal disability and sleep disorder. An attempt was made to obtain additional service personnel records, additional VA treatment records were obtained, and the Veteran was afforded a VA medical examination in July 2012. The claims were again remanded in March 2013 for addenda to the examination reports. A VA medical opinion was obtained in July 2013. The Board concludes that it may proceed with a decision on the issues above as there has been substantial compliance with the prior remand instructions. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Significantly, neither the appellant nor his representative have identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, 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. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Unlike service connection on a direct basis, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 do not require competent medical nexus of a link between the qualifying chronic disability and military service. Service connection is presumed unless there is affirmative evidence to the contrary. See 38 C.F.R. § 3.317(c); Gutierrez v. Principi, 19 Vet. App. 1 (2004). Persian Gulf Veteran means a Veteran who, during the Persian Gulf War, served on active military, naval, or air service in the Southwest Asia theater of operations, which includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e). For purposes of section 3.317, there are two types of qualifying chronic disabilities: undiagnosed illnesses and medically unexplained chronic multi-symptom illnesses. 38 C.F.R. § 3.317(a)(2). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. It is noted that: Functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficult swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least 6 months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least 3 months prior to diagnosis. 38 C.F.R. § 3.317, Note to Paragraph (A)(2)(I)(B)(3). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: fatigue; signs or symptoms involving skin; headache; muscle pain; joint pain; neurologic signs or symptoms; neuropsychological signs or symptoms; signs or symptoms involving the respiratory system; sleep disturbances; gastrointestinal signs or symptoms; cardiovascular signs or symptoms; abnormal weight loss; and menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Lastly, compensation shall not be paid under § 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c) . In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). A. Gastrointestinal Disorder Service treatment records include a March 1992 entry noting the Veteran complained of stomach cramps as well as other concerns. In November 2005 the Veteran complained of lower abdominal pain, discomfort with urination and bowel movements. The impression was early appendicitis versus prostatitis versus diverticulitis. An x-ray of the abdomen showed nonobstructive gas pattern and the diagnosis code was minor abnormality. In February 2006 the Veteran complained of lower abdominal pain. He had pain with urination and defecation. He was assessed with questionable prostatitis and constipation. The Veteran underwent an x-ray of the abdomen in February 2006 which was normal and unchanged from the prior examination. The Veteran reported that he was treated at a private hospital for right diverticulitis in April 2006. In May 2006 the Veteran complained of right sided abdominal pain that radiated to both testicles and dysuria. An outside emergency room reported diverticulitis; however, the May 2006 treatment note indicated that it did not sound like it. The active problem list included diverticulitis and abdominal pain. The Veteran was assessed with questionable recurrent urinary tract infection. In September 2006 the Veteran complained of pain in his lower abdomen and was noted to have a history of diverticulitis. The Veteran complained of abdominal cramping in April 2007. The Veteran was noted to have diarrhea that was most likely viral. The Veteran was noted to have a history of abdominal pain in December 2006. The Veteran had a barium enema that revealed possible diverticulitis. Irritable bowel syndrome/irritable bowel disease was questioned. In June 2007 the Veteran was afforded a VA medical examination. The Veteran reported that he began having flares of diverticulitis in March 2006 when he was hospitalized for three days due to severe abdominal pain with constipation lasting from one week, 10 to 12 times since March 2006. Antibiotics resolved the condition over 7 days. A barium enema examination in September 2006 was noted to reveal no active disease and mild sigmoid diverticulosis. After examination the Veteran was diagnosed with diverticulosis of the sigmoid colon. The examiner rendered the opinion that the diverticulosis is not secondary to medications prescribed for his lumbosacral strain. The rationale provided was that diverticulosis and diverticulitis is caused by a mechanical weakness in the colonic mucosal layers and medical evidence provided and current medical evidence does not support that medications of any type can cause or precipitate this condition. Abdominal cramps were noted in August 2007. The Veteran denied bleeding, abdominal pain, and fevers. He was assessed with diverticulosis. In October 2007 the Veteran complained of stomach problems, cramping, and diarrhea. The Veteran was assessed with irritable bowels. In April 2009 the Veteran was afforded a VA medical examination. After examination the examiner noted that the Veteran did not have any undiagnosed illnesses. The Veteran reported that he believed that he was having a bout of diverticulitis/constipation in July 2011. In July 2012 the Veteran was afforded a VA medical examination. The Veteran was noted to be diagnosed with diverticulitis, gastroesophageal reflux disease (GERD), and hiatal hernia. It was noted in the medical history that at delayed entry examination in 1988 the Veteran reported rectal fissure, had no trouble since then. The Veteran stated that he has to watch very closely what he eats, he has been diagnosed with diverticulosis/diverticulitis and lactose intolerance. He stated that this was diagnosed in approximately 2009 by his primary care physician. He stated that his gastrointestinal (GI) problems were diagnosed by barium enema. He was placed on special diet of high fiber and told to avoid seeds or nuts. He was also told to avoid lactose. He stated that he has a flare approximately every two months with constipation, "bad" gas. He stated the pain will be in the lower abdomen and that he takes off two to three days at a time, has nausea and then heartburn. The examiner noted that he was diagnosed with GERD in 2009 to 2010. The Veteran was on Omeprazole daily. He denied intestinal infections since 2008. He stated that he was hospitalized for three days but recovered and there was nothing since then. He never found out about the infection. He had hemorrhoids with occasional bleeding on the toilet paper. After examination the examiner rendered the opinion that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The Veteran was not diagnosed with irritable bowel syndrome (IBS). He had a diagnosable condition identified as GERD, hiatal hernia, diverticulitis, and lactose intolerance. The examiner noted that according to his history he did not have the symptoms associated with IBS such as bloating, alternating constipation, and diarrhea. The abdominal pain was related to diverticulitis which was described as flare ups from diverticulosis. A VA medical opinion was obtained in July 2013. After review of the claims file the opinion was rendered that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided the rationale: I did not find any complaints of [abdominal] pain while in the military and actually he did not begin to complain of abdominal pain until late 2005. He was diagnosed with diverticulitis and diverticulosis in 2006. Currently it appears to be stable based on what he eats. His complaints did not begin until 12 years after separation and no indication he had any problems while in the military. Therefore it is my opinion that his GI condition is less likely as not caused by or incurred during active service and/or is not related to any incident of service. Entitlement to service connection for a gastrointestinal disorder is not warranted. Initially, it is noted that the Veteran has diagnosed gastrointestinal disorders of GERD, hiatal hernia, diverticulitis, and lactose intolerance. Therefore, there is no undiagnosed illness. In addition, during the period on appeal the Veteran was noted to have irritable bowels, multiple examinations and the remainder of the treatment notes do not reveal any diagnosis for irritable bowel syndrome or any unexplained functional gastrointestinal disorder. As such, entitlement to service connection based upon the Veteran's service in Southwest Asia is not warranted. It is acknowledged that the Veteran was noted to complain of stomach cramping while in service; however, the evidence does not reveal any diagnosis or treatment for any gastrointestinal disorder until many years post service. After examination in July 2012 the opinion was rendered that the Veteran's gastrointestinal disorder was not due to the Veteran's active service. This opinion was again rendered after a review of the claims file by a VA medical examiner in July 2013. As such, the preponderance of the evidence is against a finding that the Veteran's gastrointestinal disorder was incurred in service. Although the Veteran claims that his gastrointestinal disorder is related to medication provided to treat lumbosacral strain, the June 2007 VA examiner rendered the opinion that the Veteran's disorder was not secondary to medications prescribed for lumbosacral strain reasoning that the diverticulosis and diverticulitis is caused by a mechanical weakness in the colonic mucosal layers and medical evidence provided and current medical evidence does not support that medications of any type can cause or precipitate this condition. As the preponderance of the evidence is against a finding that the Veteran's gastrointestinal disorder was incurred in service, may be presumed to have been incurred in service, or is due to or permanently aggravated by a service-connected disability, service connection is denied. B. Sleep Apnea On a Report of Medical History at entrance to service the Veteran reported "frequent trouble sleeping." In October 1992 the Veteran complained of having a sleeping disorder for six months. Reported going to bed at 2100 and not being to wake up in the morning. On a Report of Medical History at exit from service in January 1993 the Veteran did not report trouble sleeping. The Veteran was afforded a VA medical examination in April 2009. After examination the Veteran was noted to "may or as likely as not have sleep apnea. It is more likely due to probably the weight gain. There is always speculation that PTSD contributes." The examiner referred the Veteran for a sleep study. In a May 2009 addendum the examiner stated that a physical questionnaire dated in 1988 was marked by the Veteran with frequent trouble sleeping. It was noted that if a sleep study showed sleep apnea it would be as likely as not service connected. In a November 2009 addendum the examiner discussed the results of the sleep study, which revealed mild sleep apnea. The examiner rendered the opinion that it was "as likely as not that the sleep apnea is service related." Weight gain was noted to be the more likely cause of his sleep apnea, the majority of which was in service, and that "PTSD may contribute." The Veteran was afforded a VA medical examination in July 2012. The Veteran was noted to be diagnosed with obstructive sleep apnea. The Veteran reported that when he returned from the Gulf War his wife told him he was awake and asleep, tossed and turned. He indicated that his wife told him he would stop breathing. The Veteran reported that he went to sick call in 1992 and was seen for a sleep disorder. He stated that he had problems falling asleep and would wake up after approximately three hours and remain awake for about 30 minutes before going back to sleep. This would cycle three to four times nightly. He was placed on sleeping medications which caused him to oversleep in the mornings. He stated that he had to stop the medication related to his over sleeping affecting his job. He was not diagnosed or tested for sleep apnea while in the military. He came to VA in 2009 for a compensation and pension examination. He was seen for muscle and joint pain. The examiner asked him if he ever had a sleep study. He was sent for a sleep study which came back as mild sleep apnea. The Veteran was noted to be diagnosed with sleep apnea and to be on a CPAP machine. The examiner noted that service treatment records revealed one episode/complaint of sleeping disorder times six months in 1992 where the Veteran stated that he went to bed at seven to eight p.m. and was not able to wake up in the mornings to get to work on time. After physical examination the examiner rendered the opinion that the Veteran's sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The Veteran's service treatment record indicates one episode/complaint of sleeping disorder which was ongoing for six months in 1992. He reported that he went to bed at seven to eight p.m. and was not able to wake up in the mornings to get to physical training (PT) on time. His discharge physical examination did not mention this issue in 1993. There were no records available to record any symptoms of sleep apnea until the doctor at compensation and pension examination asked if the Veteran had any history of sleep apnea. The Veteran was then sent for a sleep study. He was diagnosed with mild sleep apnea. He was placed on CPAP in 2010, used several times weekly but not consistently. The examiner discussed a literature search that indicated that obstructive sleep apnea is a disorder that is characterized by obstructive apneas and hypopneas caused by repetitive collapse of the upper airway during sleep. Daytime sleepiness is a common feature of obstructive sleep apnea (OSA) as well as insomnia. As an example, the patient may admit to consistently falling asleep while reading, watching television, or even while operative a motor vehicle. In addition, embarrassing or inappropriate episodes of sleep (eg, at religious services, while driving) may be reported. Sleepiness is the inability to remain fully awake or alert during the wakefulness portion of the sleep-wake cycle, while fatigue is the subjective lack of physical or mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities. It is often unclear whether a patient's complaint of daytime sleepiness represents true sleepiness or fatigue. In addition, there are conditions that should be considered in the differential diagnosis of OSA because the similarly cause abrupt awakenings or abnormal sounds or sensations during sleep. Snoring is far more common than OSA. Therefore, even though most patients who have OSA snore, most patients who snore do not have OSA. GERD can mimic OSA by producing a choking sensation and dyspnea. In addition, GERD may improve with positive airway pressure therapy, further mimicking OSA. Other disorders can mimic OSA include swallowing disorders, nocturnal seizures and psychiatric illnesses such as panic attacks. A VA medical opinion was obtained in July 2013. After review of the claims file the examiner rendered the opinion that it was less likely than not that the Veteran's claimed condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided the rationale that: On a Report of Medical History Dated 17 Sept 1988 when the Veteran was premilitary and a civilian he reported that he did have trouble sleeping (this was prior to enlistment). While in the military on 7 Oct 1992 he did complain of a sleep disorder because he would go to bed at 2100 and not be able to wake up in the AM. No other complaints of sleep problems during his enlistment that I found. Although the Veteran was diagnosed with Mild Sleep Apnea in 2010 it is my opinion that it is less likely as not related to his active military service or his PTSD. No cause and effect relationship has been found in significant medical research studies to date between PTSD and sleep apnea. PTSD does not cause sleep apnea but it is well known that people with the diagnosis of PTSD do have sleep problems and in fact many people with sleep apnea actually have concomitant PTSD but again one does not cause the other. There is no nexus between the two diagnoses. Weight gain can contribute to the onset and recognition of sleep apnea but his [complaints] in service were not [typical] of sleep apnea and he had sleep problems prior to his enlistment into active military. He was diagnosed with sleep apnea in 2010. Thereafter, the examiner marked the box indicating that the claimed condition is at least as likely as not proximately due to or the result of the Veteran's service connected condition. However, it is noted that this statement is not followed by any independent rationale. Service connection for a sleep disorder is not warranted. Initially it is noted that the Veteran has been diagnosed with obstructive sleep apnea and, therefore, does not have an undiagnosed illness. In addition, sleep apnea is not a disability for which service connection is warranted based upon service in Southwest Asia. It is acknowledged that the Veteran had a single complaint of trouble sleeping in service. In addition, it is acknowledged that a VA medical examiner in April 2009 and subsequently in addenda in May 2009 and November 2009 indicated that the Veteran's sleep apnea was as likely as not service connected. The examiner noted that the Veteran's weight gain was more likely the cause of his sleep apnea and that the majority of this was in service. However, subsequent examiners have rendered the opinion that the Veteran's sleep apnea is not related to the Veteran's active service. The examiner in July 2012 based this opinion on review of the medical literature and indicated that obstructive sleep apnea can be mimicked and masked by other disorders. An opinion in July 2013 also stated that the Veteran's sleep apnea was less likely as not related to his active service. The examiner indicated that although weight gain can contribute to the onset and recognition of sleep apnea, the Veteran's complaints in service were not typical of sleep apnea and the Veteran had sleep problems prior to his enlistment into active military service. As such, service connection on a direct basis is not warranted. It is further acknowledged that a VA medical examiner in April 2009 and in subsequent addenda in May 2009 and November 2009 indicated that the Veteran's PTSD contributed to his sleep apnea. However, an examiner rendered the opinion in July 2013 that although it is well known that people with a diagnosis of PTSD do have sleep problems and that many people with sleep apnea have concomitant PTSD, one does not cause the other. The examiner indicated that no cause and effect relationship has been found in significant medical research studies between PTSD and sleep apnea and that there was no nexus between the two disorders. It is acknowledged that the examiner in July 2013 checked the box at the end of the examination report indicating that the claimed condition is at least as likely as not proximately due to or the result of the Veteran's service connected condition. However, this mark, followed by no rationale, is not supported by the examiner's thorough explanation that the Veteran's sleep apnea is not related to his PTSD. As such, service connection for sleep apnea as due to a service connected disability is not warranted. As the preponderance of the evidence is against a finding that the Veteran's sleep disorder was incurred in service, may be presumed to have been incurred in service, or is due to or permanently aggravated by a service-connected disability, service connection is denied. ORDER Service connection for a gastrointestinal disorder, to include as due to an undiagnosed illness, is denied. Service connection for a sleep disorder, to include as due to undiagnosed illness and as secondary to service-connected PTSD, is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs