Citation Nr: 21001210 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 17-31 155 DATE: January 7, 2021 ORDER Service connection for sleep apnea, as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. REMANDED Service connection for burn scars is remanded. FINDING OF FACT The Veteran’s sleep apnea is caused by his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for sleep apnea, as secondary to service connected PTSD, have 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 July 1997 to July 2000. The case is on appeal from January 2014 and June 2014 rating decisions. In February 2019, the Board denied service connection for sleep apnea and remanded the issue of service connection for burn scars. In a March 2020 order, the Court of Appeals for Veterans Claims (Court) vacated and remanded only that part of the February 2019 Board decision that denied a rating higher than 50 percent for PTSD prior to July 15, 2016, and denied service connection for sleep apnea. In a July 2020 decision, the Board denied a rating higher than 50 percent for PTSD prior to July 15, 2016, and remanded the issue of service connection for sleep apnea, to include as secondary to service-connected PTSD. The issue of service connection for sleep apnea is addressed in the decision below. The issue of service connection for burn scars is being remanded and is addressed in the remand section. Service connection for sleep apnea, as secondary to service-connected PTSD. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(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.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The Veteran seeks service connection for sleep apnea. He maintains that sleep apnea is secondary to service-connected PTSD. Initially, the record reflects a diagnosis of sleep apnea. As such, the current disability element of the claim is established. Thus, the remaining question is whether the Veteran’s sleep apnea is proximately due to or the result of his service connected PTSD. Both the October 2020 VA opinion and the June 2020 opinion from Dr. T.S., a private physician, reflect that the Veteran was diagnosed with sleep apnea by sleep study in July 2007. See June 2020 Correspondence. Although the exact mechanism by which PTSD leads to sleep apnea was noted to not be completely understood, Dr. T.S. reported that the essential relationship was thought to be PTSD-induced sleep fragmentation, which leads to increased collapsibility of the airway, mediated by either or both of the following pathways: hypothalamic-pituitary-adrenal (HPA) axis inhibition coupled with central activation of corticotropin releasing hormone (CRH) neuronal pathways and hippocampal dysfunction affecting inspiratory effort. Id. Although the VA opinion notes that sleep apnea is not caused by PTSD, Dr. T.S. reported significant developments in sleep science in the previous 11 years since the 2009 study referenced in the opinion, citing to a multitude of medical literature reflecting sleep apnea is a well-recognized complication of PTSD. See October 2020 Third Party Correspondence. Of particular importance with respect to the issue of causation on a secondary basis is the date of symptom onset, rather than the date of a confirmed diagnosis. See October 2020 Third Party Correspondence. In that respect, even though the diagnosis of sleep apnea chronologically preceded the diagnosis of PTSD in 2014, Dr. T.S. reported that PTSD symptoms had their initial onset in 2000, before the symptoms of sleep apnea, i.e. breathing problems during sleep, in 2001. The Board notes that although there is some discrepancy with respect to the date of symptom onset calling in to question the Veteran’s credibility, a November 2012 record reflects the Veteran’s history of sleep apnea symptoms since 2001. See June 2020 private record. Although a bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a health care professional, see LeShore v. Brown, 8 Vet. App. 406, 409 (1995), Dr. T.S. found the Veteran’s assertions as to symptom onset to be credible, noting his description in that respect was consistent with the natural history of the disease process. See also June 2020 & June 2017 private opinions. Based on review of the pertinent records and medical evidence, to include recent medical studies supporting the causal relationship between PTSD and sleep apnea, Dr. Seiter concluded it was at least as likely as not that the Veteran’s service connected PTSD caused his current sleep apnea. In this case, the Board finds that the evidence, to include the October 2020 addendum opinion, is in at least equipoise, and thus, resolving doubt in favor of the Veteran, service connection for sleep apnea, as secondary to service-connected PTSD, is warranted. REASONS FOR REMAND Service connection for burn scars. Pursuant to the February 2019 Board remand, the Veteran was afforded a VA examination in October 2019 with respect to the appeal of service connection for burn scars. It does not appear that the claim has been readjudicated, and thus, remand is required. The matter is REMANDED for the following action: Readjudicate the issue of service connection for burn scars. If the benefit sought remains denied, issue a supplemental statement of the case (SSOC). E. BLOWERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Taylor 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.