Citation Nr: A20018537 Decision Date: 12/15/20 Archive Date: 12/15/20 DOCKET NO. 200129-59343 DATE: December 15, 2020 ORDER Service connection for sleep apnea as secondary to posttraumatic stress disorder (PTSD) is granted. FINDINGS OF FACT The currently diagnosed sleep apnea is causally related to the service-connected PTSD. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the Appellant, served on active duty from October 1966 to September 1968. The Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105, also known as the Appeals Modernization Act (AMA), creates a new framework of review for veterans disagreeing with VA’s decision on their claim. This decision has been written consistent with the new AMA framework. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2020 rating decision from the Regional Office (RO), which continued the denial of service connection for sleep apnea. In January 2020, the Veteran submitted a timely Notice of Disagreement (NOD) with the January 2020 rating decision and selected direct review of the issue on appeal by a Veterans Law Judge. Service Connection for Sleep apnea The Veteran contends that service connection for sleep apnea is warranted as due to the service-connected PTSD. Service connection may be established on a secondary basis for disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). 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. 38 C.F.R. § 3.310(c). Establishing service connection on a secondary basis essentially requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(c). Initially, the Board notes that there is a current diagnosis of sleep apnea, as reflected in the May 2019 private treatment record, which indicates that an April 2019 home sleep study and May 2019 in-lab sleep study confirmed severe obstructive sleep apnea (OSA). A March 2019 rating decision granted service connection for PTSD. After reviewing all the evidence, both lay and medical, the Board finds that the evidence is in equipoise on the question of whether the current sleep apnea disability was caused by the service-connected PTSD. Mental health treatment notes indicate that upon return from service in the Vietnam War, the Veteran presented with PTSD symptoms of darkened mood, rapid mood swings, increased anxiety and hypervigilance, heavy drinking, and nightmares that interfered with sleep. The Veteran’s wife reported that she has noticed increased problems with poor sleep, including awakening multiple times a night, excessive snoring, restless legs throughout sleep, and daytime fatigue. Private treatment records indicated a history of snoring, witnessed apnea, and excessive daytime sleepiness, as well as a history of hypertension, depression, and PTSD symptoms. Upon undergoing sleep studies in April 2019 and May 2019, a diagnosis of severe OSA was rendered with recommendation to start CPAP treatment. See May 2019 private treatment record; September 2018, January 2019, April 2019, May 2019 VA treatment records. The VA examiner in August 2018 opined that it is less likely than not that the Veteran’s sleep apnea was proximately caused by PTSD. The VA examiner explained that the medical literature does not support a correlation between PTSD and OSA. The VA examiner noted that the Veteran’s is obese with a BMI of greater than 32 and obesity is commonly recognized as a cause of PTSD. August 2018 VA examination report; however, the record does not indicate that the Veteran’s BMI is greater than 32, as treatment notes only indicate a BMI that ranged between 30 and 32, and a BMI screening indicated that the Veteran’s BMI was within acceptable ranges. Additionally, despite the Veteran’s mild obesity, sleep medicine physicians did not indicate that obesity was a cause or risk factor of his OSA, and weight loss was not recommended to treat his sleep apnea despite sleep study results showing severe sleep apnea. See May 2019 private treatment record, April 2019 VA treatment record. Moreover, the VA examiner did not consider the onset of sleep apnea symptoms after the development of PTSD, and did not render an opinion regarding whether the service-connected PTSD aggravated sleep apnea, that is, worsened sleep apnea beyond its natural progression. The Veteran’s treating physician, who is Board certified in sleep medicine, indicated that a sleep study confirmed severe OSA that requires nasal CPAP for treatment. The examiner noted that the Veteran served in the military from 1966 to 1968, and he developed PTSD and depression due to service. The treating physician indicated that the PTSD led the Veteran to have disrupted and poor quality sleep, as well as increased alcohol consumption. This has led to snoring and apnea with the Veteran awakening gasping for air, as well as the development of restless leg syndrome. The physician indicated that the Veteran does not have other risk factors that precipitated his severe OSA and opined that the Veteran’s sleep apnea is highly likely related to his PTSD. See October 2019 private treatment record. A VA examiner in December 2019 also opined that it is likely that the Veteran’s sleep apnea is related to his PTSD. The VA examiner explained that the current severity of the service-connected PTSD warrants by proximity association of the sleep apnea, as the sleep apnea began subsequent to the service-connected PTSD and is the direct result of the antecedent PTSD. Additionally, the medical literature from the national sleep foundation found a high risk for sleep apnea in veterans with PTSD. See December 2019 VA examination report. Based on the above, and resolving reasonable doubt in favor of the Veteran, service connection for sleep apnea, as secondary to the service-connected PTSD, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The grant of secondary service connection renders moot other theories of service connection. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Moore The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.