Citation Nr: 18147976 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 17-37 873 DATE: November 6, 2018 ORDER Service connection for obstructive sleep apnea (OSA), to include as secondary to the service-connected posttraumatic stress disorder (PTSD) disability, is denied. FINDING OF FACT The Veteran’s OSA was not incurred in service, was not causally or etiologically related to service, and was neither caused nor aggravated by his service-connected PTSD disability. CONCLUSION OF LAW The criteria for service connection for OSA, to include as secondary to service-connected PTSD disability, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 2007 to November 2012. Although his DD-214 shows discharge under other than honorable conditions, a December 2013 administrative decision determined that his discharge was under honorable conditions for VA purposes. Service Connection—Laws and Regulations 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. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2017). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Analysis The Veteran asserts that his OSA began during active duty service, or alternatively, resulted as secondary to his service-connected PTSD disability. After review of all the evidence, lay and medical, the Board finds that the Veteran’s OSA did not have its onset during service and was not caused by or aggravated by his service-connected PTSD disability. The Veteran is currently diagnosed with OSA. See e.g., June 2015 private sleep study. The Veteran’s service treatment records contain a September 2011 post-deployment health assessment and a February 2012 reassessment, in which he stated “yes” for problems sleeping or still feeling tired after sleeping. In a January 2012 treatment note, the Veteran complained of difficulty sleeping due to ruminations of deployment, and the mental health professional stated that the sleeping disruption was related to his mental health. Thereafter, in June 2012, a PTSD screening within his service treatment records showed that symptoms such as frequent recall, nightmares, and difficulty sleeping, potentially indicated PTSD. During a March 2015 VA examination for PTSD, the VA examiner identified sleep disturbance and chronic sleep impairment due to PTSD, and in support cited to the aforementioned complaints of sleep difficulties in the Veteran’s service treatment records. A private June 2015 polysomnogram report from the Sleep Medical Center showed a diagnosis of OSA, but made no reference to its etiology, to include in-service occurrence. Subsequently, in a letter dated in September 2016, the medical director of the Sleep Medical Center confirmed that the Veteran was diagnosed with OSA in June 2015 and was treated with a APAP machine, which improved the quality of his sleep significantly. Moreover, it was further noted that, during his last appointment in August 2016, the Veteran reported feeling more rested and less sleepiness during the day when using the machine. In his October 2016 notice of disagreement, the Veteran stated that his claim should be considered secondary to his PTSD. He stated that the September 2015 letter above indicated that his sleep apnea was related to the sleep disturbances caused by his PTSD. He further noted that he began having difficulty sleeping while on active duty, was constantly tired during the day, and was prescribed sleep medications that never helped. Lastly, he indicated that he was not provided with a sleep study in-service, and reported that since discharge he continued to have difficulty sleeping and feeling tired during the day. The RO obtained a June 2017 medical opinion regarding the nature and etiology of the Veteran’s sleep apnea. After reviewing the claims file, the VA examiner opined that the Veteran’s sleep apnea was not incurred in or caused by the continuation of the symptoms or trouble sleeping in-service. The examiner explained that the in-service complaints were related to the Veteran’s service-connected PTSD, and there was no evidence of symptoms related to OSA in-service. Furthermore, the examiner noted that the Veteran’s current AHI was 6, which was borderline normal, three years after discharge from service. The examiner further opined that the Veteran’s OSA was less likely than not was proximately due to or the result of his service-connected PTSD. In this regard, the examiner explained that there were many studies done on the relationship between PTSD and sleep apnea; however, none of these studies reached the conclusion that PTSD caused OSA. The examiner further explained that central sleep apnea was linked to have a causal relationship with PTSD, but this Veteran had a documented OSA, not central sleep apnea. Lastly, the examiner opined that the Veteran’s OSA was not aggravated beyond its natural progression by his service-connected PTSD. The examiner explained that there was no evidence of aggravation of the Veteran’s OSA, since it was diagnosed when it was mild, and had not shown any signs or symptoms of progression. In his July 2017 substantive appeal, the Veteran indicated that there were many studies documenting a correlation between sleep apnea and PTSD. Alternatively, he stated that he had many complaints of daytime sleepiness while on active duty, which were likely the “beginning warning signs” of his sleep apnea. Lastly, he again stated that he was not given a sleep study in-service, and while his doctor recommended that he lose weight to help with his diagnosed sleep apnea, after losing weight there was no change. After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence is against the Veteran’s claim. Although the Veteran reported symptoms such as daytime sleepiness during service, a careful review of the STRs and post-service medical record continuously showed that his difficulty sleeping in-service and post-service was directly linked to his PTSD. Notably, during service it was noted to be “due to ruminations of deployment,” and at no time sleep apnea was suspected. In other words, it was concluded that the sleepiness was related to the chronic sleep impairment and disturbed sleep as a result of nightmares and flashbacks related to his service-connected PTSD. Furthermore, while the Veteran indicated that the letter from his private physician showed that his sleep apnea was related to the sleep disturbances caused by his PTSD, a careful review of the letter indicates that it did not make any such reference to the Veteran’s PTSD, but rather just noted that since his apnea occurred during REM sleep, it may provoke waking up and remembering dreams. The Board notes that the Veteran is competent to describe symptoms of daytime sleepiness and other sleep problems he experienced at any time; however, under the facts of this case, he is not shown to have the requisite medical expertise needed to provide a competent opinion regarding the etiology of a complex medical condition such as OSA. On the contrary, the Board assigns high probative value to the June 2017 VA examiner’s opinion. The examiner reviewed the claims file, noted the in-service complaints and explained that those were related to the Veteran’s PTSD and not symptoms of OSA. Furthermore, the examiner explained the difference between obstructive and central sleep apnea and their relationship to PTSD, as well as noted the level of severity of the Veteran’s OSA, and explained why it was not aggravated by his service-connected PTSD. The VA examiner’s opinion was demonstrably fully informed of the pertinent factual premises of the case and provided a fully articulated opinion with supporting reasoned analysis explaining why the Veteran’s PTSD could not cause and did not aggravate his OSA and why it was not related to the documented in-service complaints. See Nieves-Rodriguez, 22 Vet. App. 295, 303-304 (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Moreover, as noted above, no medical professional has linked the Veteran’s OSA to his active duty service or his service-connected PTSD disability. Because the preponderance of the evidence is against the claim for service connection for OSA on direct and secondary bases, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ROMINA CASADEI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel