Citation Nr: 21004076 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 17-07 871 DATE: January 25, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is denied. FINDING OF FACT The Veteran’s OSA was not caused by or aggravated during service and is not secondary to his service-connected left knee and bilateral lower extremity disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for OSA, to include as secondary to the service-connected left knee and bilateral lower extremity disabilities, have not been met. 38 U.S.C. §§ 1110, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the National Guard that included a period of active duty for training (ACDUTRA) in the National Guard from April 1992 to September 1992. He also served on active duty from July 1999 to March 2000, March 2003 to November 2003, and May 2008 to July 2009. This matter is on appeal from an August 2015 rating decision. In September 2019, the Veteran testified before the undersigned during a video conference hearing. A transcript of his hearing is of record. The Board remanded the matter in February 2020. Entitlement to service connection for OSA. Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. See 38 U.S.C. § 1110; Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). The term “active service” includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred or aggravated in line of duty. 38 U.S.C. §§ 101(24); 38 C.F.R. § 3.6(a). National Guard and Reserve service generally includes periods of ACDUTRA and/or INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505; 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(c). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Daye v. Nicholson, 20 Vet. App. 512 (2006). Under the benefit-of-the-doubt rule embodied in 38 U.S.C. § 5107(b), in order for a claimant to prevail, there need not be a preponderance of the evidence in the veteran’s favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1994). Three contentions have been made regarding the etiology of the Veteran’s OSA. In October 2009 and March 2010, he stated that it was related to his service in Iraq and an undiagnosed illness. See October 2009 and March 2010 Statements in Support of Claim. In January 2017, he contended that his service-connected compartment syndrome and left knee disabilities limited his ability to exercise and that since a VA examiner stated the OSA was due to weight gain it should be considered a positive opinion. See February 2017 Form 9. During the September 2019 hearing, the Veteran’s representative asserted that the Veteran’s OSA is related to his allergic rhinitis and bilateral turbinate, which has been known to lead to sleep apnea. See September 2019 Hearing Transcript. The Veteran had ACDUTRA from April to September 1992 and active duty from July 1999 to March 2000, March to November 2003, and May 2008 to July 2009. His service treatment records include the initial November 1991 enlistment examination and medical history reports that are silent for complaints or findings associated with OSA. Subsequent examinations and medical history reports during periods of active duty and between periods of active duty are also silent except for a June 2005 record that shows he snored at night and that he believed it was due to allergies and respiratory congestion. This evaluation was not during a period of active duty or ACDUTRA. See January 2010, January 2013, and October 2014 STR – Medical - Photocopy The record shows that the Veteran’s OSA was diagnosed in April 2007 between his second and third periods of active duty. See August 2015 Medical Treatment Record – Non-Government Facility. Beginning with the first contention, the Veteran’s sleep apnea has been attributed to a known clinical diagnosis, so the presumptive regulations pertaining to an undiagnosed illness or other qualifying chronic disability under 38 C.F.R. § 3.317 are not applicable. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. This does not preclude the Board from considering service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). As for the third contention, which the representative raised during the hearing, he is essentially asserting secondary service connection for OSA based on allergic rhinitis and bilateral turbinate. However, service connection is not in effect for allergic rhinitis or bilateral turbinate, so this theory is without legal merit. As for his OSA being secondary to service-connected left knee and bilateral leg disabilities by way of his obesity, obesity itself it is not a disability for VA purposes. See Marcelino v. Shulkin, 29 Vet. App. 155 (2018). However, service connection under 38 C.F.R. § 3.310 may be warranted if obesity is an intermediate step between a service-connected disability and non-service-connected disability. See VAOPGCPREC 1-2017. For obesity to be an intermediate step, the evidence would need to reflect that (1) a service-connected disability or disabilities caused the veteran to become obese or aggravated the veteran’s obesity, (2) the obesity or aggravation of obesity resulting from service-connected disability or disabilities was a substantial factor in causing another disability, and (3) the disability would not have occurred but for the obesity caused by the veteran’s service-connected disability or disabilities or the obesity aggravated by the service-connected disability or disabilities. See Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). The opinions of record that address the Veteran’s obesity are not in agreement. Therefore, the Board must determine which opinions have more probative value. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). A February 2016 treatment record from the Veteran’s pulmonologist noted the Veteran’s OSA. The physician stated that obesity is most likely the contributing factor for his sleep apnea and indicated that if his obesity is felt to be service connected, then since this led to OSA, there would be an indirect connection to OSA. See December 2016 CAPRI record. In May 2016, the Veteran requested an opinion from a VA clinician stating that leg disabilities contribute to his obesity because his pulmonologist believed his OSA was due to his obesity. He reported that he was unable to run or walk fast due to these service-connected disabilities. The Veteran was asked if he had tried other forms of exercise and he responded that he could ride a bike, but he was not going to spend money on it. In the May 2016 correspondence from his physician, who reviewed the Veteran’s history and physical examination, she wrote that the chronic conditions associated with pathology in the Veteran’s legs and knee likely contribute in part to his obesity, as they make weight-bearing exercise and associated weight loss difficult. See December 2016 CAPRI records. On November 2017 VA examination, the physician opined that the Veteran’s obesity was less likely than not a result of his physical impairment due to service-connected bilateral exertional compartment syndrome. The examiner notes that there are no records in the claims file to show the Veteran had a profile while on duty due to physical inability to perform any duties or complete physical fitness. In fact, in February 2016 the Veteran was seen for a medical visit and the record noted he lost 40 pounds while on deployment but had gained it all back when he returned. This led the examiner to believe that the Veteran was gaining weight due to lifestyle choices as he was able to function in increased activity oversees resulting in weight loss. However, when he returned his lifestyle voluntarily changed, which led to weight gain. In May 2014, the Veteran was seen for only a complaint of occasional wheezing when running, which suggests he was able to do cardiovascular exercise that would help in weight loss. The evidence does not support any significant physical impairment leading to his weight gain; rather, it was more likely a result of lifestyle choices. Thus, it is less than a 50 percent likelihood that the Veteran’s obesity was proximately due to or the result of his service-connected bilateral leg disability and left knee disability. In an addendum to this opinion, the physician stated that it is more than likely the Veteran’s obesity plays a large role in his sleep apnea, although his symptoms are likely multifactorial. It is common medical knowledge that obesity is a risk factor for development of obstructive sleep apnea and the more obese the person is the more likely the condition will arise and/or be worse. See November 2017 C&P Exam. In November 2019, Dr. K. Holton evaluated the Veteran due to persistent bilateral lower extremity pain and dysfunction. He noted that the Veteran’s exertional compartment syndrome was positively tested and confirmed in November 2007. His function has essentially been unchanged, and this does alter his ability to be physically active with exercise or normal walking. This will directly impact his ability for weight loss and increasing physical endurance in the future. See December 2019 Medical Treatment Record – Non-Government Facility. On April 2020 VA examination, the Veteran reported that after he came back from serving in 2003 his friends told he that he snored and that it got worse to the point where he could not stay in the cabin with them. He reported that this occurred around 2004 or 2005. In service, he had six to seven hours of sleep at night and he did not describe difficulty with waking up or starting the day’s activities. He did have difficulty driving due to sleepiness in 2004/2005 time period. He noted his weight was between 200 and 225 pounds in the service and that after service his weight gravitating back to 240 pounds. When he was finally tested and diagnosed with OSA in 2007, he kept it hidden because he was close to retirement and he felt that the diagnosis was looked down upon. The Veteran reported getting surgery in 2008 for his OSA, but it did not resolve the problem. After his 2003 deployment, he deployed again in 2009, and he noted he did not use his CPAP during his deployment due to his concern that the diagnosis would affect his military stay. When he returned, he started using his CPAP again. See May 2020 C&P Exam. Based on the review of the claims file to include multiple lay statements, the clinician opined that the Veteran’s obstructive sleep apnea is less likely than not related to or had its onset during the Veteran’s second period of active duty service from March 2003 to November 2003. There is no evidence of any event, injury or illness during that approximate six month term of deployment that could have resulted in sleep apnea. The Veteran was at his best weight status after his deployments when his activity level was greatest. Obstructive sleep apnea due to weight gain and obesity (rather than intermittent sleep apnea, which is caused acutely by respiratory depressants due to excess intake of alcohol) does not develop over such a short period of time but typically develops over time gradually and is most commonly associated with untoward weight gain and obesity. The only mechanism by which sleep apnea would develop over such a short term (e.g. six months) is if the Veteran had experienced significant weight gain during that short period of his 2003 deployment, and that is not noted to be the case. The clinician also noted there is suspected heavy alcohol use that likely precipitated respiratory depression and apnea. Medical record from hepatology in 2017 documents higher alcohol use with friends than when Veteran was with his son. What may seem peculiar is that, although the buddy statements report concerns with snoring and possible apnea after the Veteran’s deployment in 2003, the Veteran did not follow up with a sleep study or any treatment until 2007. In his 2003 post-deployment health assessment, he noted that his health “stayed the same or got better.” A few years later, in 2010, the General Medical examiner noted: “His buddies complained about his snoring, and he went for a sleep study.” The 2010 General Medical examiner further documents that subsequent to the diagnosis of sleep apnea, the Veteran had uvuloplasty/T & A surgery and also achieved a 40 pound weight loss (that the Veteran was able to achieve in the years after diagnosis of bilateral lower extremity compartment syndrome). The narrative suggests that the Veteran’s sleep apnea was resolved by his weight loss and surgery: “He does not wear CPAP for this [sleep apnea]. He had surgery for this.” The clinician also opined that the Veteran’s OSA was less likely than not caused or aggravated by the service-connected leg disabilities. This is concluded because medical records do not support that the Veteran’s bilateral lower extremity disabilities caused a level of physical impairment that would be expected to result in weight gain and obesity. The Veteran is service connected for bilateral lower extremity compartment syndrome, which was diagnosed in November 2007. The clinician noted that in early 2012, the Veteran was seen for left knee pain that occurred when his left leg missed the bike pedal while bicycling and he had knee surgery later that year. The Veteran was diagnosed with sleep apnea in April 2007, several months before the diagnosis of the bilateral lower extremity compartment syndrome and several years before onset of his left knee disability. Medical records through the years consistently note a preserved high level of physical activity after the onset of the Veteran's bilateral lower extremity disabilities. A September 2009 letter from the Veteran attested to his well-preserved physical capabilities. Documentation of the Veteran's 2010 General Medical Exam findings on physical included the following: "The veteran was able to fully squat and return to a standing position." Also documented by the examiner in the 2010 General Medical exam is the following regarding the Veteran's activity level and capability: "He has a history of bilateral compartment syndrome, [of the lower extremities] . . . and therefore is on a biking program for the guards rather than running, and he is able to walk 5 to 10 miles." Psychologic testing in 2013 documents that the Veteran engaged in "hunting, fishing, camping and other outdoor activities" without documentation of any expressed concern by the Veteran that his bilateral lower extremity compartment syndrome/left knee caused any limitations of these highly physical pursuits. The 2010 General Medical exam and the psychologic testing in 2013 endorse a diagnosis of alcohol abuse in the Veteran, noting consumption of four liters of rum per month. Alcohol is well-known to cause respiratory depression (reduced drive to breathe), which can cause apnea. Medical records through the years consistently document a history of alcohol excess with guidance to cut down or stop drinking. In the 2019 buddy statements, all three of the Veteran's longstanding fishing, hunting and camping comrades seem to infer that the Veteran's apnea began as soon as he returned from his deployment in 2003. Sleep apnea does not develop as acutely (e.g. over six months) as the Veteran's buddy statements seem to suggest it did unless it were acute apnea mediated by the respiratory depressive effects of alcohol. It is possible that the Veteran enjoyed excess alcohol during these social gatherings, which, if consumed in excess over a relatively short amount of time, would cause sleep apnea given the respiratory depressant effects of alcohol. Medical records from 2017 continue to verify a pattern of excess alcohol use, and the hepatology note from December 2017 noted that the Veteran reported consuming more alcohol when with friends than during times when he had visitation with his son. The clinician stated that careful examination of the medical records supports that the Veteran's bilateral lower extremity compartment syndrome and left knee disability did not result in a level of physical impairment that would correspond to weight gain and obesity. Thus, the Veteran's sleep apnea is less likely than not caused or aggravated by his bilateral leg and left knee disabilities. See May 2020 C&P Exam. After review of the medical opinions, the Board finds that the seemingly favorable February 2016 opinion is predicated on obesity being service connected. However, as noted, obesity is not a disorder that can be service connected; thus, the opinion does not have any probative value to support the claim. The May 2016 and November 2016 VA opinions and November 2019 private opinion are probative and therefore carry some weight, but the Board finds the November 2017 and April 2020 VA opinions are the most probative because the rationales are more thoroughly explained and more consistent with the other evidence of record. The Board notes that the Veteran was first diagnosed with having OSA in April 2007 and that at the time he weighed 213 pounds and his body mass index was 29.7. The General Counsel opinion noted that a person with a BMI of 30 kg/m2 or more is considered obese. See VAOPGCPREC 1-2017. Therefore, he was essentially obese at the time he was diagnosed with OSA. However, the most probative evidence does not show that his obesity is due to his service-connected disabilities. The November 1992 enlistment examination for the National Guard shows the Veteran’s weight was 154 pounds and at the end of this period his weight was 161 in September 1992. From that point until April 1996 his weight increased to 201 pounds. When he entered his second period of active duty in March 2003 his weight was 196 pounds. See January 2010 STR – Medical – Photocopy. Prior to his deployment in May 2008, a March 2008 service medical examination shows the Veteran’s weight was 223 pounds. During his deployment his weight is shown to have gone down to as low as 178 pounds in December 2008. See January 2010 STR – Medical – Photocopy. Thus, the evidence shows that the Veteran gained weight primarily when not on active duty and, consistent with the VA examiners, he was able to lose a substantial amount of weight during his third period of active duty, which was after his bilateral leg disability was diagnosed. The record is also consistent with the 2017 and 2020 VA opinions in that the bilateral leg disabilities did not prevent him from being physically active. His service treatment records show he was given a temporary three month profile in April 2005 for anterior compartment syndrome. The profile shows he could not do a two mile run, but he could still do an APRT walk, swim, and bike. He was also able to do standard or modified aerobic conditioning. See January 2010 STR – Medical – Photocopy. The Veteran was eventually given a permanent profile and in September 2009 he submitted a statement that the profile authorized him to take a bike test instead of a two mile run and that his condition does not affect his job or deployability status. He stated that he met the weight standard and could also meet the APFT standards with his permanent profile. All duties could be performed including walking at own pace and road marches with all required gear for WOCS. In January 2011, the Veteran reported that his bilateral leg cramps occurred at least three times a week and were not associated with much pain and he did not have any weakness. Ibuprofen also helped. See May 2011 Medical Treatment Record – Non-Government Facility. An April 2014 treatment record indicates the Veteran was running and only complained of occasional wheezing associated with it; he also tried increasing his running. In July 2015, he reported that he walked for fitness. See August 2015 CAPRI records. On August 2016 VA examination, the clinician noted that an April 2014 VA treatment record indicated that he had been running in preparation for a test in his National Guard unit. The Veteran denied having any knee pain while walking. The clinician found there was no functional impact due to the left knee disability. See September 2016 C&P Exam. On November 2016 VA examination for the bilateral lower extremity leg disability, the Veteran reported that he was able to run up until 2005 and had to stop due to leg cramping. He had leg cramping if he pushed himself too hard. He reported that he could not walk or run more than 200 yards and speed walk up to a ¼ mile. He indicated that he consistently had fatigue-pain. On examination his strength was 5/5 and the clinician indicated that the functional impact involved developing tightness and pain with moderate exertion that impacted ability to climb stairs, walk briskly or run. See November 2016 C&P Exam. On the contrary, a November 2016 treatment record also shows that the Veteran reported he would be resuming hunting soon and would be getting more exercise. See December 2016 CAPRI records. This suggests his ability to exercise was not as limited as he reported on his November 2016 VA examination. Treatment records in October 2017, April 2018, May 2018, and February 2019 also show that the Veteran’s bilateral leg disabilities did not prevent him from being active or exercising. The Veteran was walking, exercising, doing yard work, and hunting. See March 2020 CAPRI records. Based on the above, the record shows that the Veteran gained the majority of his weight prior to being diagnosed with the bilateral leg disability and that even with some physical restrictions he was not prevented from being physically active or completing the physical training associated with his service. He even lost weight during his last deployment. Thus, the evidence is consistent with the November 2017 and April 2020 opinions that the Veteran’s service-connected left knee and bilateral lower extremity disability did not cause or aggravate his obesity. The November 2017 VA examiner’s opinion that the Veteran’s obesity is primarily attributed to his lifestyle choices is also consistent with the record. Concerning the lifestyle choices, the November 2017 and April 2020 VA examiners pointed out examples of the Veteran’s alcohol intake and activity levels. The Board also notes that service treatment records show that in June 2005 he reported drinking three to six sodas a day and drank three to four alcohol drinks two to three times a week. See January 2010 STR – Medical – Photocopy. In September 2009, he reported that for the past year he drank two to three times a week and typically had three or four drinks on the days he drank. See October 2009 CAPRI records. A February 2012 VA treatment record shows a significant amount of time was spent with the Veteran discussing how to change some habits, food choices, amount eaten, and exercise to include adding cardio and weightlifting. He was encouraged to eat less than normal, and exercise. In March 2013, the Veteran denied exercising regularly. An alcohol screening shows he drank two to three times a week and three to four drinks each time. See July 2013 CAPRI records. In July 2015, he reported that he had six alcohol beverages a week. He was aware that he was obese and declined MOVE. See August 2015 CAPRI records. In February 2017, he reported that he had 12 drinks in the last seven days and that he binged twice in the last 30 days. February 2017 VA treatment records state that his alcohol use exceeded recommended limits. March 2017 VA treatment records noted that the Veteran was overweight and indicated that he has a problem with having an excessive appetite. He also acknowledged that weight gain was a negative consequence of his drinking. See May 2017 CAPRI records. Thus, the November 2017 and April 2020 VA opinions are consistent with the record concerning the Veteran’s alcohol intake, overeating, and activity level. The May 2016 opinion is less probative because while it states that the Veteran’s bilateral lower extremity disabilities contributed, in part, to his obesity, which the Board notes addresses aggravation, she did not address the second and third points needed to establish obesity as an intermediate step. Namely, she did not opine whether the aggravation of his obesity by the service-connected disabilities was a substantial factor in causing the Veteran’s OSA, or whether but for the obesity aggravated by the bilateral lower extremity disabilities the OSA would not have occurred. Without addressing all three points, the opinion lacks probative value to grant the claim. Dr. Holton’s November 2019 opinion is also less probative because the physician’s statement does not directly address the causal or aggravation requirements to establish obesity as an intermediate step for secondary service connection. Instead, the physician states that the bilateral compartment syndrome directly impacts the Veteran’s ability to lose weight as it alters his ability to be physically active with exercise or normal walking. This opinion only addresses the Veteran’s inability to lose weight/reduce his obesity rather than stating the disabilities cause or aggravate it. Furthermore, the statement is inconsistent with the record. The physician states that the Veteran’s bilateral lower extremity disability has remained unchanged since it was diagnosed in 2007 and also states that it alters the Veteran’s ability to exercise and be physically active. However, the record shows that the Veteran was able to lose 40 pounds during his active duty from May 2008 to July 2009, which was after the compartment syndrome diagnosis, and that subsequent post-service treatment record shows he has continuously been able to hunt and engage in other physical activities. Thus, his opinion is inconsistent with the record. The November 2017 and April 2020 VA examiners also pointed out evidence that contradicts the statement regarding the limitations level of activity. Therefore, the opinion does not adequately support the claim. For the reasons stated, the Board finds that more probative evidence is against secondary service connection. The Board has also considered service connection on a direct basis. A March 2010 statement from J. B., who served with the Veteran during his deployment in 2008, states he was frequently awakened by the sound of the Veteran gasping for air during the night. See March 2010 Buddy/Lay Statement. In September 2019, J. H. submitted a statement that said he had known the Veteran for 20 years and during that time they had many overnight trips together. Prior to the Veteran’s deployment, the Veteran did not have any sleep related issues; he did not snore or have difficulty breathing when he slept. After the deployment in 2003, he witnessed the Veteran’s sleeping issues on multiple occasions. The Veteran snored loudly, and it seemed like he would not breathe for periods of time. He stated that he informed the Veteran of this at least 50 times before he finally got tested. See September 2019 Buddy/Lay Statement. K. W. provided a similar statement in September 2009 about not noticing the Veteran’s snoring or breathing issues before his deployment in 2003. After the deployment he noticed in October and November the Veteran snored loudly and on multiple occasions he stopped breathing. See September 2019 Buddy/Lay Statement. M. K. also did not notice any breathing or snoring problems during their overnight trips prior to the 2003 deployment. He added that approximately two weeks after the Veteran returned from deployment was when he first noticed the Veteran’s snoring and gasping for air. This continued and worsened for a couple of years until he was eventually tested and diagnosed. See September 2019 Buddy/Lay Statement. The only medical evidence of record that addresses direct service connection is against the claim. An opinion was obtained in November 2016 to determine if the Veteran’s OSA was directly related to his service. He reported that it began in 2007 and that he had a sleep study after he had been sleeping next to a group of people who told him his snoring was much worse and that he had stopped breathing for a while. He did not do well without a CPAP and he continued to have daytime sleepiness. He also had to increase his pressure several times since being diagnosed. The physician opined that the Veteran’s OSA was less likely incurred in or caused by service because an episode of snoring does not cause sleep apnea and that it is typically a symptom of sleep apnea. He added that the Veteran already had a well-established diagnosis of OSA in April 2007, so it was less likely incurred while on active duty from May 2008 to July 2009. See November 2016 C&P Exam. The April 2020 VA unfavorable opinion also offered a probative opinion and a very persuasive rationale that was adequately supported by the evidence and took into consideration the Veteran and his friends’ lay statements. The Board has considered the lay statements that indicate the Veteran’s symptoms started after his deployment in 2003, but they conflict with what he reported on his November 2017 VA examination that it began in 2007. He did previously report snoring at night, but he dismissed this as being related to his allergies and congestion. While the lay statements are competent to document the symptoms that were observed after the Veteran’s second period of active duty, none of the individuals are shown to have the medical education or experience to offer a nexus opinion concerning sleep apnea, as this is diagnosed through testing. See Savage v. Gober, 10 Vet. App. 488, 494-97 (1997); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). No medical evidence has been submitted or obtained to indicate the Veteran’s OSA is related to service. Furthermore, as previously discussed, the more probative evidence weighs against service connection on a secondary basis. For these reasons stated, the Board finds that a preponderance of the evidence is against the claim. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Bredehorst 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.