Citation Nr: 20021999 Decision Date: 03/30/20 Archive Date: 03/30/20 DOCKET NO. 19-17 364 DATE: March 30, 2020 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to service connection for diabetes mellitus, type II, is remanded. FINDING OF FACT The Veteran’s sleep apnea is at least as likely as not aggravated by his service-connected PTSD. CONCLUSION OF LAW Resolving doubt in favor of the Veteran, service connection for sleep apnea is warranted as secondary to his service-connected PTSD. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from October 1973 to October 1976. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for sleep apnea The Veteran contends that he is entitled to service connection for sleep apnea as secondary to his indirect exposure to dioxins or service-connected PTSD. See April 2017 VA Form 21-526EZ. For the reasons explained below, the Board finds that entitlement to service connection for sleep apnea is warranted. In order to obtain service connection under 38 U.S.C. § 1110 and 38 C.F.R. § 3.303 (a) a Veteran must satisfy a three element test: (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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Secondary service connection may be granted for disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310 (a). The evidence must show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc) (holding that when aggravation of a non-service-connected disability is proximately due to or the result of a service connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation). As an initial matter the Board notes that the Veteran is currently service connected for post traumatic stress disorder (PTSD) rated as 70 percent disabling. The Veteran was afforded a VA sleep apnea examination in May 2017 where the examiner opined that the Veteran’s sleep apnea was less likely than not related to his exposure to dioxins or secondary to his PTSD. The examiner reasoned that the Veteran’s exposure to dioxins was speculative and was not severe enough, prolonged enough or direct enough to cause sleep apnea. Further, the examiner opined that there was no medical literature linking sleep apnea to herbicide agent exposure. The examiner opined that the Veteran’s sleep was most likely due to his non-service-connected chronic obesity and body habitus. A June 2017 addendum opinion states that “accepted medical literature does not indicate that PTSD is a known cause of obstructive sleep apnea.” In June 2019, the Veteran, through his representative, submitted a sleep apnea disability benefits questionnaire (DBQ) authored by Dr. M.B. She opined that it was at least as likely as not that the Veteran’s service-connected PTSD aggravated his sleep apnea. “It is my opinion it is at least as likely as not [that the Veteran’s] service connected PTSD and the medications used to treat his PTSD have aided in the development of and permanently aggravate his obstructive sleep apnea... Research has shown that PTSD and other psychiatric disorders are commonly associated with OSA. A recent study found an arousal-based mechanism initiated by posttraumatic stress that promotes the development of OSA in trauma survivors.” She explained that research has shown that antidepressants affect sleep and treatment with an SSRI can produce or exacerbate problems with sleep disturbance. She also noted that the Veteran’s prescription Clonazepam which is in the family of drugs that are known to worsen sleep-related breathing disorders. She further explained that “[i]t is not possible to determine how much the Veteran’s PTSD and medications used to treat his PTSD cause in aggravation of his sleep apnea when comparing these to his obesity. All have likely played a role in the development and permanent aggravation of his sleep apnea.” Based on the foregoing, the Board finds that the evidence in support of and against the claim are in relative equipoise and therefore finds that entitlement to service connection for sleep apnea is warranted. On the one hand, the VA medical opinion, found that there was no nexus between the Veteran’s OSA and his service-connected PTSD or any potential herbicide agent exposure. The VA examiner found that the Veteran’s OSA was more likely related to obesity. On the other hand, the private opinion from Dr. M.B. states that the Veteran’s OSA is more likely than not aggravated by his service-connected PTSD. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Both medical professionals are competent to provide a medical opinion regarding the etiology of the Veteran’s OSA. Both examined the Veteran and provided opinions supported by adequate rationale. However, they arrived at opposite conclusions. Here, Dr. M.B.’s medical opinion weighs in favor of the grant of service connection, while the negative nexus VA examination report and opinion weighs against the claim. The Board finds that the cumulative weight of the favorable evidence is equal to the weight of the negative evidence; and resolving doubt in favor of the Veteran, the claim of entitlement to service connection for sleep apnea is granted. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). As such service connected for the Veteran’s obstructive sleep apnea as secondary to his service-connected PTSD is warranted. REASONS FOR REMAND Entitlement to service connection for diabetes mellitus, type II is remanded. The Veteran contends that he is entitled to service connection for diabetes as secondary to his service-connected PTSD or as due to indirect exposure to herbicide agents. See April 2017 VA Form 21-526EZ. The Veteran was afforded a VA diabetes mellitus examination in May 2017 where the examiner opined that the Veteran’s diabetes was less likely than not related to his service-connected PTSD. The examiner reasoned that medical literature does not indicate that PTSD is a cause of diabetes. The examiner attributed non service-connected reasons for the Veteran’s diabetes. However, the examiner did not address whether the Veteran’s PTSD aggravated his diabetes mellitus. Secondary service connection is available for those disabilities caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310. Thus, the Board finds that a remand is necessary to obtain an addendum medical opinion which adequately addresses all theories of entitlement. The matter is REMANDED for the following action: Obtain an addendum opinion from the May 2017 VA examiner (or a suitable medical professional) to address the etiology of the Veteran’s diabetes mellitus. The electronic claims folder, including a copy of this remand, must be made available to the examiner for review in connection with the opinion. The examiner is requested to review the electronic claims file (and note such a review) and offer an opinion as to the following: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s diabetes mellitus was incurred in or is otherwise related to service. (b.) Whether it is at least as likely as not (50 percent probability or greater) the Veteran’s diabetes mellitus was caused or aggravated by his service-connected PTSD. If aggravation is found, provide the baseline manifestations and the increased manifestations. The Board is returning the matter for an addendum opinion because the May 2017 examination report does not address the theory of aggravation of a non-service-connected disability by a service-connected disability. A complete rationale for all opinions must be provided. Attention is invited to the Veteran’s contentions noting that his diabetes mellitus has been caused or aggravated by his service-connected PTSD. K. R. Kardian Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Baskerville 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.