Citation Nr: 20009787 Decision Date: 02/06/20 Archive Date: 02/05/20 DOCKET NO. 16-07 609 DATE: February 6, 2020 ORDER Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT The Veteran’s sleep apnea is not etiologically related to service and is not caused by or aggravated by the service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for a sleep apnea disability, to include as secondary to the service-connected PTSD disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1974 to August 1977 and from September 1990 to July 1991. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a February 2011 rating decision. The Veteran appeared at a hearing before the undersigned Veterans Law Judge in March 2017. In November 2016 and January 2018, the Board remanded the case for further development. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a June 2019 correspondence, the Veteran requested to revoke the representation of her prior representative. To date, the Veteran has not submitted documentation appointing a new representative; as such, the Board finds that she wishes to be unrepresented in this appeal. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service” the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Additionally, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was proximately caused or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran seeks service connection for sleep apnea. She notes that that her sleep problems began in 1991 after serving in Desert Storm. She reports using a continuous airway pressure machine (CPAP). (See March 2017 Board hearing). Service treatment records do not show any complaints or treatment for problems sleeping. Post-service private treatment records dated in July 2009 show complaints of difficulty sleeping. She reported frequently waking up, having nightmares and daytime sleepiness. A private treatment record shows an assessment of obstructive sleep apnea (OSA) in October 2009. A VA PTSD examination report dated in March 2011 reflects that the Veteran had noted sleeping problems in the past. An April 2016 medical opinion shows that the VA examiner had reviewed the Veteran’s claims file and stated that research had indicated that PTSD was not necessarily associated with a higher prevalence of OSA; however, OSA may increase the severity of PTSD. The VA examiner noted that the preponderance of medical evidence and medical body of the current knowledge did not support that PTSD caused OSA, noting a difference between central sleep apnea found in the limbic system and obstructive sleep apnea. The VA examiner noted that in adults, the most common cause of sleep apnea was excessive weight and obesity. The Veteran was afforded a VA examination in September 2018. The Veteran reported snoring, feeling fatigued, sleeping while driving, and needing sudden gasps of air when sleeping. She noticed a significant difference when using a CPAP machine. The VA examiner noted a review of the Veteran’s claims file and opined that the Veteran’s obstructive sleep apnea was less likely as not incurred in or caused by the claimed in-service injury, event or illness. The VA examiner noted that there were no findings in the medical records provided that indicated issues while in service or in the following years to ascribe service correlation to the current diagnosis, devoid of speculation. The VA examiner also stated that the Veteran’s claimed condition was not at least as likely as not aggravated beyond its natural progression by PTSD. The VA examiner noted that OSA involved the velopharyngeal and/or oropharyngeal airway collapsing (recurrently) during sleep, resulting in reduction/loss or airflow. It was more an anatomical dysfunction and was not impacted by the Veteran’s PTSD or mental disorder (which has no impact on oropharyngeal airway anatomy). The Veteran’s enlarged turbinates and low oropharynx were more likely the reason for OSA. The VA examiner noted that PTSD may result in insomnia, which was separate from OSA. After the review of the record, the Board finds that the VA medical opinions regarding direct and secondary service connection weigh against a finding of a relationship between the Veteran’s sleep apnea, active duty and her service-connected PTSD. The opinions provided by the VA examiners are persuasive evidence, opposing rather than supporting the claim, because the opinions accurately reflect the evidence of record and thorough examinations, and provide a rationale and plausible explanations for concluding that the Veteran’s sleep apnea was not the result of her military service and her service-connected PTSD. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, there are no medical opinions to the contrary. The April 2016 medical opinion indicates that OSA may increase the severity of PTSD but contained no opinion suggesting the contrary and in fact reflects that there was a lack of support for the finding that PTSD caused OSA. The Veteran is certainly competent, as a lay person, to report symptoms of which she has personal knowledge, such as sleep loss, and the Board finds her account credible. Layno v. Brown, 6 Vet. App. 465 (1994). However, as a lay person without training or credentials, she is not competent to establish a medical diagnosis or show a medical etiology by her own assertions, as such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1). The specific issue in this case, the relationship between sleep apnea and service or a service-connected disability, is a complex medical issue and outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In light of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran’s claim of service connection for sleep apnea because the competent and persuasive evidence does not show that the sleep apnea condition is either related to her active duty service and/or caused or aggravated by the service-connected PTSD. As such, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection for the Veteran’s sleep apnea on a direct and secondary basis is not warranted. See 38 C.F.R. § 3.310. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A-L Evans, Counsel 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.