Citation Nr: 20021252 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 17-40 180 DATE: March 25, 2020 ORDER Entitlement to service connection for sleep apnea is denied. FINDING OF FACT The preponderance of the evidence is against finding that sleep apnea began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran honorably served in the United States Army from August 1968 to June 1970. This matter appears before the Board of Veterans’ Appeals (Board) on appeal of a May 2013 rating decision of the Regional Office (RO) in St. Petersburg, Florida. In February 2019, the Board remanded the Veteran’s claim of entitlement to service connection for sleep apnea for an addendum opinion discussing secondary service connection. In September 2019, VA requested an addendum opinion, and in November 2019 an opinion was provided. The Board finds substantial compliance with its previous remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for sleep apnea The Veteran contends that he is entitled to service connection for sleep apnea. Specifically, the Veteran contends that his sleep apnea is secondary to his service-connected disabilities including, coronary artery disease (CAD), prostate cancer residuals, unspecialized anxiety disorder, bilateral hearing loss, tinnitus, erectile dysfunction, and cardiac surgical scars. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of a service-connected disability or is aggravated beyond its natural progression by a service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of obstructive 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, any service-connected disability or disabilities. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The Veteran submitted a September 2011 letter by Dr. S.R.C. which stated, in part, that the Veteran’s sleep apnea could more likely than not adversely affect his service-connected CAD. However, Dr. S.R.C.’s opinion is silent as to whether the Veteran’s sleep apnea is caused or aggravated by his service-connected CAD. In October 2011, the Veteran was afforded a VA examination where the examiner concluded that sleep apnea was not proximately due to or the result of CAD. The examiner explained that a medical literature review did not support any such nexus. The Veteran underwent a VA examination again in May 2017. This examiner concluded that a current medical literature and research review did not support a cause and effect relationship between sleep apnea and prostate cancer. Further, the examiner explained that there is no literature to support sleep apnea is caused by anxiety. Rather, the examiner noted the Veteran had multiple non-service related risk factors for sleep apnea, to include advancing age (he was diagnosed at age 63) and the male gender. In June 2017, an addendum opinion was obtained to discuss aggravation. The June 2017 examiner concluded that the Veteran’s sleep apnea is not aggravated by CAD, mental disorder, and/or prostate cancer. He explained there is no objective evidence of aggravation. In fact, while the examiner noted medical evidence suggesting sleep apnea could aggravate CAD and other heart-related diseases, there was no evidence to support the reverse was true, that CAD could aggravate sleep apnea. A thorough and detailed rationale was provided to support this opinion. In January 2019, the Veteran’s representative submitted articles and links to medical studies suggesting an association between sleep apnea and heart disease. As such, the Board remanded the claim in February 2019 to obtain an addendum opinion to consider the articles submitted. An addendum opinion was obtained in November 2019 where the examiner again concluded that sleep apnea is less likely than not caused by service-connected CAD, prostate cancer residuals, anxiety disorder, bilateral hearing loss, tinnitus, and surgical scars. The examiner addressed the articles submitted by the Veteran, finding that the articles discuss the effects of sleep apnea on cardiovascular disease (and not the other way around). In particular, the examiner explained that sleep apnea “occurs when there is a block in the airway passage that leads to decrease in brain oxygenation.” Risk factors include “age and gender.” The articles reviewed show “[i]ndividuals with severe sleep apnea are at increased risk for coronary artery disease, congestive heart failure, and stroke.” That is to say that someone with sleep apnea is more likely to develop heart disease, but “this is the inverse of the causation being asked in this opinion….” For these reasons, the examiner’s opinion remained unchanged, that it was “less likely than not” that the Veteran’s service-connected disabilities caused or aggravated his sleep apnea. The Board finds the VA medical opinions of record are well reasoned, based on thorough review of the record, the Veteran’s contentions, and his specific case. The Board finds them to be of high probative value. The articles submitted by the Veteran and the private opinion by Dr. S.R.C., moreover, do not support the Veteran’s claim. Rather, they merely show that the Veteran’s non-service-connected sleep apnea could cause or aggravate his heart conditions (and not the other way around). The only evidence indicating the Veteran’s sleep apnea is either caused or aggravated by his service-connected disabilities is his own lay statements. In that regard, the Board has considered his statements and acknowledges the Veteran believes his sleep apnea is proximately due to or aggravated beyond its natural progression by a service-connected disability. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge the interaction between multiple organ systems in the body and anatomical relationships. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). (Continued on the next page)   Consequently, the Board gives more probative weight to the medical evidence of record. The Board concludes the preponderance of the evidence is against finding that sleep apnea is caused by or aggravated by the Veteran’s service-connected disabilities. Accordingly, entitlement to service connection for sleep apnea secondary to service-connected disabilities is not warranted. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. N. Fournier, Associate 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.