Citation Nr: 18154752 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 14-05 501 DATE: December 3, 2018 ORDER Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for narcolepsy is granted. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran’s obstructive sleep apnea is etiologically related to active service. 2. The evidence is at least in equipoise as to whether the Veteran’s narcolepsy is etiologically related to active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 2. The criteria for entitlement to service connection for narcolepsy have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Army from June 1994 to May 2002. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in April 2017. A copy of the transcript has been associated with the claims file. This case was most recently before the Board in December 2017, at which time it was remanded for further development. The case has since been returned to the Board for appellate adjudication. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disability 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). Generally, in order to establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). 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). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is 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 facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 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. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the evidence shows the Veteran has been diagnosed with both obstructive sleep apnea and narcolepsy. VA treatment records show the Veteran was diagnosed with sleep apnea following a January 2009 sleep study, and with narcolepsy in January 2011. Therefore, he meets the first requirement of service connection, a current disability. The Board finds the evidence at least in equipoise on the issue of whether the Veteran’s current obstructive sleep apnea and narcolepsy disabilities are etiologically related to active service. The Veteran’s service treatment records are of record and show the Veteran complained of a “sleeping disorder” in September 1998. At the time, the Veteran reported having dealt with the disorder for the past four years. The Veteran’s 1993 enlistment examination is silent for complaints of sleep problems, but he endorsed “frequent trouble sleeping” on his 2001 discharge examination. The Veteran was afforded a VA examination in May 2011. The Veteran reported an onset of sleep problems in childhood. He reported being “always tired” and not feeling fresh on waking after a nap or sleep. The examiner acknowledged the Veteran’s sleep apnea diagnosis but determined it was unrelated to service, suggesting instead it was related to significant post-service weight gain. Despite the Veteran’s January 2011 diagnosis, the examiner found no evidence of narcolepsy and therefore did not provide an opinion as to etiology. In a May 2016 letter, Dr. M.S. of the Gainesville VA Medical Center (VAMC) wrote that the Veteran’s “sleep apnea and related sleep problems are probably aggravated by various injuries & musculoskeletal problems sustained during military service & continue to affect his sleep.” In a May 2016 VA medical treatment note, VA Dr. R.B. wrote, “it is likely that a sleep disorder was present (at least narcolepsy) while the patient was in the service but was not evaluated with a sleep study.” At his April 2017 Board hearing, the Veteran testified that his sleep problems caused him to struggle during service, and that at one point he was almost given an Article 15 punishment for missing a formation due to oversleeping. The Veteran asserted he complained of sleep disturbances multiple times during service but was never tested for a sleep disorder. The Veteran’s wife testified that she noticed that the Veteran had sleep problems while he was on active duty. She testified that the Veteran would stop breathing and kick or hit her in his sleep, and that he would be tired and angry during the day. Multiple disability benefits questionnaires regarding the Veteran’s sleep conditions were completed in January 2018. Dr. A.B. completed an in-person examination of the Veteran and diagnosed him with obstructive sleep apnea and narcolepsy; however, Dr. A.B. did not review the Veteran’s claims file and did not provide a nexus opinion for either condition. Dr. E.M. conducted a review of the Veteran’s claims file and determined that both his obstructive sleep apnea and narcolepsy were at least as likely as not causally or etiologically related to service. In reaching his conclusion, Dr. E.M. noted the Veteran’s in-service reports of a sleep disorder and the absence of evidence of symptoms or diagnoses prior to military service. After an in-person examination of the Veteran and review of his claims file, Dr. J.F. concluded that the Veteran’s obstructive sleep apnea was less likely than not related to service or any of the Veteran’s service-connected disabilities. He did not provide a rationale to support his conclusion. Regarding narcolepsy, Dr. J.F. wrote that he was “unable to comment on the nature and etiology of narcolepsy without speculation.” (Continued on the next page)   Overall, the Board finds that the evidence, both positive and negative, is at least in equipoise on the question of whether the Veteran’s current sleep disabilities of obstructive sleep apnea and narcolepsy are etiologically related to service or the Veteran’s service-connected disabilities. The Veteran has consistently attributed his sleep issues to active duty service, and his service treatment records include complaints of sleep problems. The Veteran’s wife has also credibly corroborated the Veteran’s reports of in-service sleep problems. Moreover, multiple VA practitioners have attributed the Veteran’s sleep conditions to his active duty service or to his service-connected disabilities. The Board finds the negative evidence to be less probative, as the May 2011 VA examiner did not fully address the Veteran’s in-service complaints of a sleep disorder, and Dr. J.F. provided no rationale to support his negative nexus opinion regarding sleep apnea and no opinion at all regarding narcolepsy. Under such circumstances and granting the Veteran the benefit of any doubt in this matter, the Board concludes that the Veteran has also met the second and third requirements of service connection—an in-service occurrence and a nexus between the occurrence and the currently diagnosed disabilities. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Accordingly, the Board finds that service connection for both obstructive sleep apnea and narcolepsy is warranted because the disabilities had their onset in service. 38 C.F.R. § 3.303. L. CHU Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. T. Raftery, Associate Counsel