Citation Nr: 21001333 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 15-23 496 DATE: January 7, 2021 ORDER Entitlement to service connection for obstructive sleep apnea, to include secondary to post-traumatic stress disorder (PTSD), is denied. Entitlement to service connection for a skin disability is denied. FINDINGS OF FACT 1. The preponderance of the competent evidence does not show the Veteran’s OSA had its onset in, or is otherwise related to service, to include as secondary to his service-connected psychiatric disorder. 2. The preponderance of the evidence does not show the Veteran’s skin condition had its onset in or was otherwise caused by his military service. CONCLUSIONS OF LAW 1. The criteria for service connection for OSA, to include as secondary to an acquired psychiatric disorder, have not been met. 38 U.S.C. § 1110, 1154, 5107; 38 C.F.R. § 3.303, 3.310. 2. The criteria for service connection for a skin disability have not been met. 38 U.S.C. § 1110, 1154, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the U.S. Army from November 1988 to February 1992. He testified at a travel board hearing in July 2017 before the undersigned Veterans Law Judge. A transcript is associated with the record. The Board remanded the appeal in August 2018 and October 2020 in order to schedule VA examinations and obtain addendum opinions. Service Connection Establishing service connection generally requires (1) evidence of a presently existing disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established on a secondary basis when a disability is shown to be 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 (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. See Allen v. Brown, 7 Vet. App. 439 (1995). The competence, credibility, and probative (relative) weight of evidence, including lay evidence must be assessed. See generally 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the unique and readily identifiable features of a medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for obstructive sleep apnea, to include secondary to PTSD. Per a sleep study conducted in 2015, the Veteran has a diagnosis of obstructive sleep apnea (OSA). In the October 2020 decision, the Board granted the Veteran service connection for other trauma and related stressor disorder. Therefore, both the first and second elements of secondary service connection have been met. There is no evidence of a diagnosis of OSA or related complaints noted in the Veteran’s service treatment records. However, the Veteran indicated that he was exposed to burn pits and chemicals during service, which required him to sleep in a gas mask. The appeal turns on whether there exists a medical nexus between his current diagnosis of OSA and his service or other trauma and related stressor disorder. The Board finds that it does not. The Veteran’s wife provided a buddy statement in August 2017 indicating that she and her husband have stopped sharing a bedroom due to his excessive snoring. The Veteran was first afforded a VA examination in October 2019 and the accompanying December 2019 opinion found that his OSA was more likely than not related his psychiatric diagnosis. The examiner referenced a study published by the National Institute of Health which showed a direct correlation between PTSD and sleep apnea. Specifically, the study found that Veterans with PTSD screened as high risk for OSA at much higher rates than others, despite notes showing classic predictors for OSA such as old age and higher BMI. The opinion addressing direct service connection noted that he was diagnosed with OSA over 10 years after separation and his service treatment records were negative for any complaints, diagnosis or treatment. As such, it was less likely than not that his OSA was etiologically related to or had its onset in service. The October 2020 opinion indicated that there was no evidence in the medical literature that which demonstrated PTSD as a primary etiology of OSA. The Veteran’s OSA was more likely due to his obesity, which is well established as a cause. Treatment records show the Veteran experienced sleep apnea with intermittent wake ups well controlled on CPAP. The examiner found that this fell within the natural progression of the condition and did not represent aggravation. The examiner also found that the Veteran’s OSA is less likely than not directly related to service—mainly due to the lack of evidence in service of treatment for sleep apnea-related symptoms and the long period from the time of discharge from service to his ultimate OSA diagnosis. Again, the examiner also opined as to the likely etiology of the Veteran’s OSA. After thorough review of both the lay and medical evidence of record, the Board finds that the Veteran’s sleep apnea was not related to service or secondary to his psychiatric disability. The October 2020 examiner found that his OSA was ultimately caused by his obesity, was not directly related to service, and was neither caused nor aggravated by his service-connected psychiatric disorder. This is the most probative evidence of record as to the nexus element. The October 2020 opinion provider is qualified through education, training, and experience to offer medical diagnoses, statements, or opinions. Moreover, the opinion reflects consideration of the Veteran’s contentions that his OSA is either directly related to service or that his psychiatric disorder caused or aggravated his OSA and it makes a clear basis for the opinions. Therefore, the Board accords great probative weight to this opinion. The December 2019 opinion is considered inadequate with respect to secondary service connection because the examiner failed to show how PTSD (or any psychiatric diagnosis) was the direct cause of the Veteran’s OSA. There was no clear explanation as to why those with PTSD were at higher risk for OSA than others. The medical literature referenced by the December 2019 examiner addressed OIF, OEF, and OND, younger Veterans, not Operation Desert Storm Veterans. As such, the December 2019 opinion is affordable little probative value, and is far outweighed by the October 2020 opinions. In contrast, the October 2020 examiner considered the lay and medical evidence of record, provided a detailed rationale for the opinions reached, and included an alternate etiology for the OSA. The October 2020 examiner clearly opined that the Veteran’s OSA was neither caused, nor aggravated, by his service-connected psychiatric disorder. Further, the October 2020 examiner opined that the Veteran’s OSA was not directly due to service and included a detailed rationale and alternative etiology of the OSA. Although they are competent to relay his symptoms, including the onset of snoring in service, the Veteran and his wife are not competent to diagnose sleep apnea or link symptoms described during service to the currently diagnosed sleep apnea. Further, although obesity can be a “stepping stone” between a service-connected and another disability, the Veteran has not presented any probative evidence that a service-connected disability caused his obesity, which then caused his OSA. As for his claim that his sleep apnea is secondary to his psychiatric disorder, the probative medical evidence of record shows this is not the case. The probative opinion of record indicated that sleep apnea is due to the Veteran’s weight. And there was no medical evidence showing the Veteran’s diagnosis was caused or aggravated by psychiatric diagnosis, or any of his other service-connected disabilities. Again, the Veteran has not presented a competent medical opinion either linking the Veteran’s OSA directly to service, or as secondary to a service-connected disability. The Board has considered the Veteran’s argument that his sleep apnea had its onset in service or is due to his psychiatric disorder. In this case, the Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex as to the relationship between OSA, and service or a service-connected disability. Therefore, the October 2020 examiner’s opinions finding the Veteran’s OSA is not directly related to service or secondary to a service-connected disability are probative. In conclusion, the weight of the evidence is against the claim for service connection for sleep apnea. Reasonable doubt does not arise, and the claim is denied. 2. Entitlement to service connection for a skin disability. The Veteran was diagnosed with a sebaceous cyst on his upper back in June 2015. During service, he reported being exposed to burn pits and chemicals during his deployment overseas from 1990-91. He was responsible for using jet fuel to burn fecal matter. He began developing boils on his buttock and waistline after getting out of service in 1992. He had two surgical excisions of boils, but the condition continued to come and go. Currently, he uses over the counter boil-ease as treatment. The Veteran contends that the burn pits and fecal matter he was exposed to during service caused his current skin condition. Treatment records show the Veteran was diagnosed with a sebaceous cyst in June 2015 and had it surgically removed. An October 2019 note indicated that the only significant skin problems the Veteran experienced were folliculitis and an abscessed lumbar cyst that was surgically removed. The Veteran was afforded a VA examination in March 2014 and diagnosed with folliculitis and boils on his thighs. The examiner found that a skin condition was less likely than not incurred in or caused by service. He had one well healed papule on the right pubic area, there were no pustules or redness noted. The examiner noted that folliculitis is inflammation of hair follicles and the most common causes were from shaving the skin, physical irritations, chemical irritation, and bacterial or fungal infection of the hair follicle. The December 2019 confirmed the diagnosis of sebaceous cyst. The examiner also noted his struggles with boils following service. The accompanying opinion indicated that the Veteran’s sebaceous cyst was diagnosed over 12 years following his separation from service. The type of cyst is caused by blocked sebaceous glands. The examiner found that due to the time lapse from his deployment to the development of the cyst in 2015, it was less likely than not that his skin disorder was etiologically related to or had its onset in service. An addendum opinion was completed in October 2020. The examiner indicated that the timeline for a diagnosis of a skin condition occurred much earlier than previously discussed in the October 2019 exam. The March 2014 examination demonstrated multiple boils on waistline and underwent procedure to remove in the early-2000s. Still, the examiner found that his skin condition did not have its onset in service and the first complaints occurred approximately 10 years following service. Based on the foregoing, the Board finds that service connection for a skin condition is not warranted. There is no competent evidence showing a nexus between the Veteran’s current diagnoses and his service. The VA opinions, when taken together, are probative and the only probative evidence regarding the nexus element. The probative evidence shows that the Veteran’s folliculitis, boils, and sebaceous cysts occurred years after service and were not the kind of skin conditions that would have developed as a result of exposure to chemicals or fecal matter during service. The Veteran’s service treatment records were negative for any chronic skin diseases. Specifically, on a July 1991 demobilization medical evaluation he indicated that he did not have rashes, skin infections, or sores. His February 1992 report of medical history and separation exam did not show any skin condition. The Board has considered the Veteran’s argument that his skin condition had its onset in service. In this case, the Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex as to the relationship between the Veteran’s current skin diagnosis and his service. Therefore, the VA examinations hold more probative weight on the issue of nexus, and the examiners found no relationship between the current skin conditions and service. In conclusion, the weight of the evidence is against the claim for service connection for a skin condition. Absent a competent opinion linking the Veteran’s current skin condition to an event, injury, or disease in service, service connection must be denied. (Continued on the next page)   Reasonable doubt does not arise, and the claim is denied. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Price, 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.