Citation Nr: 18146364 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 09-47 113 DATE: October 31, 2018 ORDER Entitlement to service connection for sleep apnea, to include secondary to service-connected posttraumatic stress disorder (PTSD) and sinusitis is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for numbness/tingling of the hands is remanded. Entitlement to a total disability rating based on individual unemployability for the period prior to July 14, 2010 is remanded. FINDING OF FACT Obstructive sleep apnea did not manifest in service and is not otherwise attributable to service and was not caused or aggravated by a service-connected disease or injury. CONCLUSION OF LAW Sleep apnea was not incurred in service and is not proximately due to or the result of (causation or aggravation) a service-connected disease or injury. 38 U.S.C. § § 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. § § 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from March 1967 to March 1971, October 1990 to May 1001 and October 2003 to March 2004, to include service in Thailand and the Persian Gulf. Service Connection for Sleep Apnea Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The Veteran asserts that his sleep apnea was caused or aggravated by his service-connected PTSD or sinusitis. See Notice of Disagreement dated January 2016. The question for the Board is whether the Veteran’s current sleep apnea disability was proximately due to or the result of, or was aggravated beyond its natural progress by either service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of sleep apnea, the preponderance of the evidence is against finding that the Veteran’s sleep apnea is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability, to include PTSD or sinusitis. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The December 2015 VA examiner opined that the Veteran’s sleep apnea was less likely than not caused or aggravated by either his PTSD or sinusitis. In so finding, the examiner indicated that there was no association between sleep apnea and either PTSD or sinusitis. The examiner defined sleep apnea as a physiologic abnormality in which the pharyngeal tissues collapse during inspiration, which resulted in obstruction to air flow and hypoxemia. The examiner concluded that such a condition could not be caused or aggravated by sinusitis or PTSD. In support of his claim, the Veteran has submitted various articles, which suggest a correlation between a diagnosis of PTSD and the occurrence of sleep apnea. See Notice of Disagreement dated January 2016. In response to these articles, the Veteran was most recently afforded a VA examination in November 2017. Upon review of the claims file and examination of the Veteran, the examiner opined that the Veteran’s sleep apnea was less likely than not caused or aggravated by his service-connected PTSD or sinusitis. In so finding, the examiner acknowledged the medical articles submitted by the Veteran, but found that the information was based on a conference presentation that was not peer reviewed or replicated. Ultimately, the examiner found that there was not enough scientific information to make an association between PTSD and sleep apnea. In addition, the examiner found that sleep apnea has not been associated with any Gulf War exposures and the Veteran’s sinus condition did not result in any nasal airway obstruction that would cause sleep apnea. The Board finds both these opinions to be highly probative as to the issue of whether a nexus between sleep apnea and the Veteran’s service-connected disabilities exists. The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, both examiners considered the Veteran’s medical history in conjunction with the evidence in the claims file to arrive at the conclusion that the Veteran’s sleep apnea was not caused or aggravated by his PTSD or sinusitis. Both examiners provided adequate reasoning as to why the Veteran’s service-connected disabilities were unrelated to his sleep apnea. The Board finds that these opinions, both individually and cumulatively, are highly probative as to the issues of etiology and aggravation. These opinions comport with the other medical evidence of record and there is no probative evidence contradicting the opinions or rationales. The Board acknowledges the articles that the Veteran submitted, which suggest the existence of a correlation between PTSD in veterans and the development of sleep apnea. However, the Board finds that the probative value of the articles is substantially outweighed by the other medical evidence of record, mainly the two highly probative VA examinations. The articles are not accompanied by the opinion of any medical expert to suggest that this particular Veteran’s sleep apnea is at least as likely as not caused or aggravated by his psychiatric disabilities. The mere fact that there is evidence of a potential link between certain disabilities and obstructive sleep apnea does not demonstrate that this specific Veteran’s obstructive sleep apnea is at least as likely as not related to one of the disabilities discussed in the article. Indeed, here, the probative medical opinion evidence has indicated that there is no such relationship. In addition, the Veteran’s treating physicians have not associated his sleep apnea with his psychiatric disabilities. As such, the Board assigns the articles little probative value. The only remaining evidence in support of the Veteran’s claim is his own lay statements. While the Veteran believes his sleep apnea was either caused or aggravated by his service-connected PTSD and/or sinusitis, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examinations of record. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s obstructive sleep apnea is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran was diagnosed with obstructive sleep apnea in March 2014, a decade after discharge from his final period of active duty service. There is no evidence of any complaints or manifestations of sleep apnea during service. In addition, the November 2017 VA examiner opined that the Veteran’s sleep apnea was not a result of in-service exposures. In conclusion, there is no evidence to demonstrate that the Veteran’s obstructive sleep apnea was caused by his period of service, nor does the Veteran contend such. The probative evidence is against a finding that sleep apnea was caused by service or caused or aggravated by a service-connected disability. The claim is denied. REASONS FOR REMAND Service Connection for Hypertension The Veteran was afforded a VA examination in March 2017 to determine whether his hypertension was aggravated by either his periods of service or his service-connected disabilities. The examiner found that the Veteran’s service-connected disabilities did not cause or aggravated his hypertension. However, the examiner did not address whether the Veteran’s pre-existing hypertension was aggravated by his subsequent periods of service. Upon remand, the AOJ should obtain an addendum opinion addressing whether hypertension was aggravated beyond its normal progression by the Veteran’s last two periods of active duty. Service Connection for Numbness/Tingling of the Hands The Veteran has been afforded several VA examinations in relation to the numbness and tingling of his hands. However, a clear etiology or diagnosis has yet to be provided. At the November 2015 VA examination, the examiner diagnosed the Veteran with Gulf War Syndrome. At the March 2017 VA examination, the examiner found that the numbness and tingling in the Veteran’s lower extremities was diabetic neuropathy. However, a diagnosis or opinion was not provided for the symptoms of the Veteran’s hands. Upon remand, the Veteran should be afforded another examination to determine the nature and etiology of the numbness and tingling of his hands. The examiner should opine as to whether his symptoms are related to any of his disabilities, to include Gulf War Syndrome, fibromyalgia, and diabetes. Entitlement to TDIU prior to July 14, 2010 The issue of entitlement to TDIU for the period prior to July 14, 2010 is inextricably intertwined with the issues being remanded. Thus, the Board will defer adjudication on this issue. The matters are REMANDED for the following action: 1. Associate with the claims folder updated VA and private treatment records. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension was at least as likely as not caused or aggravated by or otherwise etiologically related to his second and third periods of service. The examiner should note that aggravation is defined as permanent worsening of the disability beyond that due to the natural disease process. The need for further in-person examination of the Veteran is at the discretion of the examiner. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any numbness and tingling of the hands. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including exposure to herbicides. The examiner should also determine whether the Veteran’s symptoms of the hands are at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. The examiner should note that aggravation is defined as permanent worsening of the disability beyond that due to the natural disease process. 4. Readjudicate the claims on appeal. If the claims are not granted to the Veteran’s satisfaction, provide him and his representative a Supplemental Statement of the Case and allow them the appropriate time to respond before returning the appeal to the Board. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Orie, Associate Counsel