Citation Nr: 21062174 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-22 750 DATE: October 6, 2021 ORDER Service connection for sleep apnea is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's sleep apnea began during active service, or that it is otherwise related to an in-service event, 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, 3.309(d), 3.311. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from July 1979 until his honorable retirement in July 1999. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 decision by the Augusta, Maine, Regional Office of the United States Department of Veterans Affairs (VA), which denied service connection for sleep apnea. Important to the Board's analysis, the Veteran claimed his sleep apnea was due to any of the following: (1) in-service diet and sleep habits required by his duties; (2) in-service exposure to contaminants and/or carcinogens; (3) in-service residuals of malaria vaccination, including blood poisoning; (4) in-service exposure to ionizing radiation; (5) in-service exposure to asbestos; and (6) in-service onset of headaches. The Veteran filed a timely appeal of the decision and did not elect to testify by the Board. In January 2019, the Board remanded the case to the VA Regional Office for further development. Specifically, the Board directed the VA Regional Office to accomplish the following directives: 1. Seek authorization from the Veteran to obtain his private medical records, specifically those from Howard County General Hospital and Johns Hopkins Medical Center. 2. Request that the Veteran complete and return an appropriate asbestos exposure questionnaire. 3. Request that the Veteran submit or cite competent scientific or medical evidence that his sleep apnea may be induced by ionizing radiation. 4. Obtain a VA examination and medical opinion addressing the etiology of the Veteran's sleep apnea. As will be discussed, the VA Regional Office substantially complied with the foregoing remand directives. The case now returns to the Board for adjudication. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claim. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection, there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. Additional legal theories of service connection will be discussed within the following analysis where appropriate. Analysis First element: A current disability According to the Veteran's private medical records, he was diagnosed with severe obstructive sleep apnea in 2010. He continues to have a diagnosis of severe obstructive sleep apnea through the present. Therefore, the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof The Veteran has asserted six factual bases on which he seeks service connection: (1) in-service diet and sleep habits required by his duties; (2) in-service exposure to contaminants and/or carcinogens; (3) in-service residuals of malaria vaccination, including blood poisoning; (4) in-service exposure to ionizing radiation; (5) in-service exposure to asbestos; and (6) in-service onset of headaches. In-service diet and sleep habits required by duties In a June 2015 correspondence with VA, the Veteran stated that in several conversations with his primary care physician, Dr. S., he was told that the diet he was served while on active duty and the irregular sleeping habits he experienced in service "most definitely contributed to [his] development of severe sleep apnea." The VA Regional Office sent the Veteran correspondence in April 2015, which included appropriate forms, informing him that he could authorize VA to obtain his private medical records. The Veteran did not return any forms or otherwise authorize VA to obtain his private medical records. As part of the Board's January 2019 Remand directives, it instructed the VA Regional Office to once again contact the Veteran and request that he complete the appropriate authorization forms so that VA may obtain his private medical records, which may have included Dr. S.'s medical treatment and/or medical opinion(s). The VA Regional Office also attempted to make telephone contact with the Veteran in August 2020 but was unable to reach him. To date, the Veteran has not returned the proper forms or otherwise authorized VA to obtain his private medical records. Outside of the Veteran's general statements about his in-service diet and sleep habits, the Board finds no additional evidence in the record reasonably related to his assertions. The Board has reviewed the Veteran's in-service medical treatment records, military personnel records, private medical records, an all relevant lay evidence and is unable to locate additional information relating to his diet and sleep habits in service. For example, there is no evidence indicating what type of diet he was served, how long he received that diet, to include its beginning and ending points, what side effects, if any, the Veteran experienced as a result of the diet while in-service, or what sleep disturbances the Veteran experienced in-service related to his diet or his military duties, to include his working hours or physical requirements. Because there is a lack of any supportive evidence, beyond the Veteran's assertions of his in-service diet and sleeping habits, the Board finds his assertions alone are not probative. See Fagan v. Shinseki, 573 F.3d 1282, 1286 (2009) (stating that the claimant has the burden to "present and support a claim for benefits" and noting that the benefit of the doubt standard in [38 U.S.C. §] 5107(b) is not applicable based on pure speculation or remote possibility). The Board is only left to speculate about what the Veteran experienced in-service with respect to his diet and sleep habits. Therefore, the Board concludes that the Veteran's generalized assertions of in-service diet and/or sleep habits, without more, do not constitute in-service event, injury, or disease for the purpose of service connection. In-service exposure to contaminants and/or carcinogens In a June 2015 correspondence with VA, the Veteran stated that he was exposed "to[] many different airborne contaminants during [his] Shipboard and Shipyard duty in the Navy." Again, he stated that his private physician, Dr. S., told him that such exposure could "most definitely contribute to [his] development of severe sleep apnea." In a June 2015 supplemental application for benefits, the Veteran stated "carcinogen exposure ships" in relation to his claim for service connection for sleep apnea. The Veteran's military medical records contain a Medical Surveillance Questionnaire in which he reported exposure to "carcinogens" and "solvents" while serving aboard the U.S.S. Andrew Jackson from January 1981 to January 1984. The Veteran's military service records confirm service aboard that vessel during that timeframe. His military occupational specialties included, Squadron Department Head, Staff Engineer Officer, Staff Readiness Engineer, Ship's Engineer, Budget Officer, Staff Material Officer, Naval Engineering Inspection Officer, Operational Intelligence Officer, Supply Logistics Officer, Surface Safety Officer, Staff Readiness Officer in submarine warfare, Watch Officer, System Security Officer, and he worked with gas turbines and underwater fire control systems. See DD-214s. Yet, it is unclear what his exact military occupation specialty was from 1981 to 1984 aboard the U.S.S. Andrew Jackson. Although the Veteran's military records document that he reported exposure to carcinogens and solvents, there is no other evidence beyond his general statements. As stated, the Veteran did not respond to any of the VA Regional Office's requests to obtain his private medical records. In addition, the Veteran did not submit any medical evidence pertaining to Dr. S.'s medical opinion. Nor has the Veteran offered any particularized information about what airborne contaminant, carcinogen, or chemical solvent he believes to which he may have been exposed. There is no other medical or lay evidence of record relating to the alleged exposure. For example, there are no medical records, in-service or post-service, that reasonably suggest exposure to such items, treatment for such exposure, nor is there any other evidence that would reasonably demonstrate such exposure. Simply stating that he was exposed to carcinogens, contaminants, and chemical solvents does not provide the Board with any information to assess the factual nature of his asserted exposure. One of the touchstones of credibility is that a person has personal knowledge of something that they assert happened to them. "Personal knowledge is that which comes to the witness through the use of his sensesthat which is heard, felt, seen, smelled, or tasted." Layno v. Brown, 6 Vet. App. 465, 469 (1994) (citing United States v. Brown, 540 F.2d 1048, 1053 (10th Cir. 1976) (witnesses may testify "upon concrete facts within their own observation and recollectionthat is, facts perceived from their own senses, as distinguished from their opinions or conclusions drawn from such facts."). Here, the Veteran has not indicated, and the evidence does not reasonably suggest, that he knew he was exposed to airborne contaminants, carcinogens, or chemical solvents. At most, the Veteran believes he was, but that is speculation based on the evidence of record. Thus, the Board does not afford his factual assertions any credibility. Even if the Board assumes the Veteran's statements are credible, the Board nevertheless finds that his statements have no probative value because they are very broad and generalized. See Fagan, 573 F.3d at 1286. The lack of any evidence to support the type, extent, or severity of exposure to such contaminants, carcinogens, or solvents is evidence that weighs against the Veteran's position. Therefore, the Board concludes that the Veteran's generalized assertions of in-service exposure to airborne contaminants, carcinogens, and chemical solvents, without more, do not constitute in-service events for the purposes of service connection as they lack credibility and probative value. In-service residuals of malaria vaccination, including blood poisoning In a June 2015 supplemental application for benefits, the Veteran stated "blood poisoning malaria vaccinations" in relation to his claim for service connection for sleep apnea. The Veteran's service treatment records indicate that he was vaccinated for malaria in August 1989. His records also documented a number of instances of vaccinations for a number of diseases; however, they are silent for any complaints, treatments, or diagnoses of blood poisoning or any other illness or disease reasonably related to his vaccinations. The Veteran's private medical records are also silent for any reasonably related diagnoses of illnesses or diseases associated with vaccinations or blood poisoning. Notably, the Veteran has not pointed to any specific symptoms, side effects, or general medical issues associated with his malaria vaccination. Again, the Veteran has not authorized VA to obtain any of his private medical records. The Board finds that the Veteran, while competent to report any physical symptoms he may have experienced after receiving a malaria vaccination, is not able to diagnose himself with blood poisoning due to a vaccination. That is a medical determination to be made by a person with the necessary knowledge, skills, and training. Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnoses). To this extent, there is no evidence of record that indicates, or that reasonably suggests, that the Veteran experienced any negative reactions or side effects associated with his malaria vaccination such that it would reasonably be related to his claim for service connection for sleep apnea. Therefore, the Board concludes that the Veteran's generalized assertion that his malaria vaccination, which he believes may have caused blood poisoning, without more, does not constitute in-service event for the purpose of service connection as the Veteran is not competent to make such an assertion as he lacks the necessary knowledge, skills, and training to do so. There is a lack of any other evidence reasonably supporting the Veteran's assertion of an in-service event, illness, or disease. In-service exposure to ionizing radiation In his March 2015 application for benefits and June 2015 supplemental application for benefits, the Veteran claimed he was exposed to ionizing radiation in service, thus leading to his sleep apnea. From the Veteran's June 2015 correspondence, the Board gathers that he asserts his exposure to ionizing radiation occurred while serving aboard various naval vessels as part of his military occupational specialties. 38 U.S.C. § 1112(c), as implemented by 38 C.F.R. § 3.309(d), provides presumptive service connection for certain (listed) diseases developed by veterans who are considered "radiation-exposed." In this case, however, presumptive service connection is not available because the Veteran's sleep apnea is not one of the listed diseases under 38 C.F.R. § 3.309(d)(2). In a separate regulation, the provisions of 38 C.F.R. § 3.311 trigger a special administrative procedure to determine service connection for certain enumerated "radiogenic diseases" exclusive of those enumerated in 38 C.F.R. § 3.309(d). First, a veteran must establish that he or she suffers from a radiogenic disease that manifested within a certain time period. 38 C.F.R. § 3.311(b)(2), (5). Once the veteran has established a diagnosis of a radiogenic disease within the specified period and claims that the disease is related to radiation exposure while in service, VA must obtain a dose assessment and request exposure data from the veteran's service branch. 38 C.F.R. § 3.311(b)(1), (2). The VA Regional Office is then required to refer the case to the Under Secretary for Benefits. 38 C.F.R. § 3.311(b). If a condition is not recognized by the regulation as a "radiogenic disease," the claim must still be referred to the Under Secretary for Benefits when a veteran "has cited or submitted competent scientific or medical evidence that the claimed condition is a radiogenic disease." 38 C.F.R. § 3.311(b)(4); see also Parrish v. Shinseki, 24 Vet. App. 391, 395 (2011) ("[Under Secretary of Benefits] has the authority to designate supervisory personnel such as the [Compensation and Pension] Director to make findings under applicable law and regulation in accordance with 38 C.F.R. §§ 2.6(b) and 3.100."). Additional procedures exist regarding referral, but those procedures are not applicable in this case because the Veteran does not meet the criteria for referral. The Veteran's sleep apnea is not a listed radiogenic disease under 38 C.F.R. § 3.311(b)(2). Thus, in order to receive the procedural benefits of 38 C.F.R. § 3.311, the Veteran must cite or submit "competent scientific or medical evidence that [his sleep apnea] is a radiogenic disease." 38 C.F.R. § 3.311(b)(4). The VA Regional Office, pursuant to the Board's January 2019 remand directive, sent the Veteran correspondence in September 2019 requesting him to submit competent scientific or medical evidence that his sleep apnea may be induced by ionizing radiation. To date, the Veteran has not submitted any such evidence. Therefore, the special administrative procedures of 38 C.F.R. § 3.311 are inapplicable to his claim. Even though the regulations found in 38 C.F.R. §§ 3.309(d) and 3.311 are inapplicable to the Veteran's claim for service connection for sleep apnea, a grant of service connection may still be made on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). To this extent, the Board finds the Veteran's military medical records documented that he was exposed to ionizing radiation in service due to his military occupational specialties between 1981 and 1984. See Record of Occupational Exposure to Ionizing Radiation. In addition, an August 1985 Medical Surveillance Questionnaire documented that he reported exposure to radiation aboard the U.S.S. Andrew Jackson from January 1981 to January 1984. Therefore, the Board finds in-service exposure to ionizing radiation did occur. As to this factual basis for service connection, the second element is satisfied. In-service exposure to asbestos In his March 2015 application for benefits and June 2015 supplemental application for benefits, the Veteran asserted in-service exposure to asbestos led to his sleep apnea. In a June 2015 correspondence with VA, he stated he was exposed to asbestos during his active service on the U.S.S. Comte De Grasse from 1990 to 1991 and aboard the U.S.S. Andrew Jackson from 1982 to 1984. The Veteran's service records confirm his service aboard these vessels in the stated timeframes. Before addressing the merits of this claim, the Board notes something concerning between the Veteran's in-service medical records obtained by VA and those submitted by the Veteran, which directly bears on the probative weight to be afforded to the documents related to his claim for service connection based on the factual theory of exposure to asbestos. Prior to filing his claim for service connection in 2015, the Veteran's claims file contained his in-service medical records that VA had obtained in February 2000. These in-service medical records are marked "BEST COPY." Some records, by virtue of their original condition, are in such poor condition that a legible copy is unattainable. [The Veterans Benefits Administration] provided the scanning vendors with specific guidelines to identify these types of documents. Specifically, if images within a document do not scan clearly or are otherwise unclear, the scanning vendors are instructed to label those items as the "best copy" available. This process identifies documents that are creased, frayed, deteriorated, torn, faded, stained, or otherwise damaged. For documents that are bent or creased, the vendor utilizes specific document reparation techniques to straighten the document for scanning. VA Claims Process: Review of VA's Transformation Efforts: Hearing Before the Senate Committee on Veterans' Affairs, 113th Cong. 19 (2013) (Testimony of Allison A. Hickey, Under Secretary for Benefits, Veterans Benefits Administration, U.S. Department of Veterans Affairs, Response to Post-hearing Questions Submitted by Hon. Mark Begich to U.S. Department of Veterans Affairs, Question 7). After the VA Regional Office denied the Veteran's claim for service connection for sleep apnea in March 2015, he submitted a Notice of Disagreement and additional documents. Among those documents were copies of his in-service medical records, which the VA evidence intake center scanned and associated with his claims file. The in-service medical records submitted by the Veteran are not marked "BEST COPY." While reviewing the Veteran's in-service medical records obtained by VA in February 2000, the Board found an August 27, 1985, medical record labeled, "Asbestos Medical Surveillance Program" that was completed as part of the Veteran's service aboard the U.S.S. Comet De Grasse. The Veteran submitted a similar document as part of his in-service medical records in June 2015. What is unusual is that the document obtained by VA and that submitted by the Veteran are different to the extent that the document submitted by the Veteran has additional (and unexplained) writing. In the February 2000 document obtained by VA, the Veteran circled "No" to the two questions asking if he was exposed to asbestos prior to his naval career and during his naval career. But in the record submitted by the Veteran, "No" and "Uncertain" are circled. In addition, in the document obtained by VA, in response to the question "Where/when were you exposed to asbestos?" the Veteran answered "N/A." Yet, in the document submitted by the Veteran, the response listed is "N/A. As officer onlisted service on USS Andrew Jackson during refits [illegible] lagging was replaced to FWD torpedo room." In the VA-obtained document, in response to the question, "Total exposure to asbestos in Years:" the answer listed was "0." But in the Veteran's submitted document, the answer listed is "0. [illegible]." This is not the only document in which there are noticeable and concerning disparities. In VA's obtained in-service medical records, there is a document dated August 19, 1996, labeled, "Asbestos Medical Questionnaire" from the U.S.S. O'Bannon. As to the three questions of whether the Veteran: (1) supervised the work of a lagging or ripping crew by remaining in the compartment where the work was accomplished; (2) recalled entering a compartment where a lagging or ripping operation was in progress; and (3) was ever exposed to any other operations involving asbestos material, the Veteran answered "No." But in the Veteran's submitted in-service medical record, the words "inspected and monitored" appear next to the answer "No" in question one, and the "X" next to the answer "No" in question 2 is scribbled out and an "X" appears next to the answer "Yes." These documents are significant in this case because they deal directly with in-service asbestos exposure. The Board finds that the documents submitted by the Veteran are inherently unreliable. First, the additional markings on the Veteran's submitted documents appear to be made with a different writing instrument from the original text as found in VA's obtained documents due to the difference in shading and pressure applied to the writing. Second, the Board observes that these edits only favor the Veteran's position. In this regard, the Board cannot overlook that fact that the Veteran may have a motive to make edits to his in-service medical records to benefit his position. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (the Board can consider bias in evidence). The Board is not going to go so far as to say the Veteran did in fact alter his in-service medical documents as the Board has no evidence of such, but there is no explanation as to how or why the documents obtained by VA in 2000 are different from the ones submitted by the Veteran in 2015. Particularly odd is the fact that the only documents that appear to be edited are those that are relevant to the Veteran's claim for service connection based on alleged asbestos exposure. On review of the evidence as a whole, the Board concludes that the in-service medical documents submitted by the Veteran in 2015 cannot be trusted because the edits in those documents logically occurred after the initial creation of the documents, and there is no proffered reason or explanation for these edits. Therefore, the Board finds that the in-service medical records obtained by VA in 2000 are the most reliable evidence as to the Veteran's in-service medical treatment and experiences as recorded therein. The Board disregards the aforementioned in-service medical records submitted by the Veteran in support of his claim for service connection because they are untrustworthy. To be clear, the Board is not disregarding every in-service record submitted by the Veteran, only those records the Board has specifically identified above. Turing to the merits of the Veteran's claimed in-service exposure to asbestos, the Board finds the evidence of record weighs against the Veteran's assertion. The Veteran's in-service medical records obtained by VA indicate he received numerous medical examinations in relation to his active service, which include exams in July 1979, August 1979, June 1983, October 1985, August 1988, June 1996, and June 1999 (retirement examination). At no point during any of these examinations did the Veteran mention being actually exposed to asbestos or under the belief that he may have been exposed to asbestos. Nor did any of the medical professionals who examined the Veteran document exposure (or possible exposure) to asbestos based on illness, injuries, or diseases exhibited or reported by the Veteran. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Next, the Veteran responded that he was not exposed to asbestos during rip-out operations or other asbestos dust operations or worked with asbestos or asbestos products prior to or during his naval career as of August 1975. August 1975 Asbestos Medical Surveillance Program Questionnaire. The Veteran completed an August 1985 Medical Surveillance Questionnaire in which he was asked to list his military service occupational history and state any potential hazards to which he was exposed. He did not list actual or potential exposure to asbestos as of August 1985. As of August 1996, he also reported that he never supervised the work of a lagging or ripping crew by remaining in the compartment where the work was accomplished, did not recall entering a compartment where a lagging or ripping operation was in progress, and was never exposed to any other operations involving asbestos material in military service. August 1996 Asbestos Medical Questionnaire. The Veteran's post-service medical records are silent for actual or potential exposure to asbestos and are also silent as to any illnesses, injuries, or diseases associated with asbestos exposure. The VA Regional Office initially requested the Veteran complete and return a questionnaire about his exposure to asbestos. April 2015 VA Correspondence. The Veteran did not provide the requested information. As part of the Board's January 2019 remand, it directed the VA Regional Office to attempt to obtain the information from the Veteran once again. The VA Regional Office sent the Veteran correspondence in November 2019 requesting information related to his asbestos exposure, but he did not respond. The Board finds there is no evidence, outside of the Veteran's generalized lay assertions, that he was exposed to asbestos while in service. His in-service medical records do not document exposure, his military personnel records do not document exposure, he explicitly denied such exposure within 1975, 1985, and 1996 medical questionnaires, and his lay statements, if assumed credible, have no probative value due their broad generalities. For example, the Veteran has only indicated he was exposed on "several occasions," including on the U.S.S. Comte De Grasse from 1990 to 1991 and aboard the U.S.S. Andrew Jackson from 1982 to 1984. He offered no additional evidence explaining how he knows (or reasonably suspects) that he was exposed, where on the vessels he was exposed, for how long he was exposed, or any other information for the Board to assess the probative value of his statements. See Fagan, 573 at 1286. As such, his lay statements are not credible, but even if they were, they have no probative value. Therefore, the Board finds the weight of the evidence is against the Veteran's assertion that he was exposed to asbestos while in service. In-service onset of headaches The Veteran's final factual basis for service connection is his assertion that his in-service onset of headaches were early symptoms of sleep apnea. He says that his sleep apnea may have started as early as 1990 based on his onset of headaches while aboard the U.S.S. Comte De Grasse, and which continued throughout the remainder of his military career. The Veteran's in-service medical records document that the received treatment for headaches on multiple occasions. In addition, his June 1999 retirement examination shows that he experienced frequent or severe headaches, although he believed they were stress-related at that time. The Veteran also offered a statement in June 2015 that after his diagnosis for sleep apnea and receipt of a CPAP machine, his headaches went away. Thus, he links his headaches to his sleep apnea. In addition, in his April 2017 VA Form 9, Substantive Appeal to the Board, the Veteran generally cited "current medical research from the AMA, and other predominant recognized medical institutions" showing a "direct correlation between migraine headaches and sleep apnea." The Veteran did not offer any additional information. The VA Regional Office obtained a medical examination and opinion in January 2020 to assess the etiology of the Veteran's sleep apnea. The examiner conducted an examination based on Acceptable Clinical Evidence (ACE). This examination allowed the examiner to review the Veteran's existing medical records instead of performing an in-person or telehealth examination to complete the examination, expediting the process by eliminating the wait time to schedule and conduct an in-person exam. The examiner indicated that he reviewed all available records, including the Veteran's virtual claims file. The examiner determined that the Veteran's records did not indicate any entries for symptoms that were suggestive of sleep apnea. The Board reasonably understands the examiner's conclusion to mean that the Veteran's in-service headaches were not symptoms suggestive of sleep apnea in service. Moreover, the examiner stated that a review of medical literature using "UPTODATE" (an online "evidence-based" medical research database, https://www.uptodate.com/home), revealed no cause-and-effect relationship between sleep apnea and headaches. The issue of whether the Veteran's in-service headaches were a symptom of sleep apnea, such that they constitute an in-service onset of sleep apnea, turns on the probative value of the available evidence. Credibility of the evidence is not at issue, as both the Veteran's statements and the examiner's statements are credible. The evidence includes the Veteran's lay statements and citation to medical literature and the VA examiner's medical findings and opinion. For the reasons that follow, the Board find the VA examiner's medical opinion is more probative than the Veteran's lay assertions and medical literature citation. The Board acknowledges the Federal Circuit has held that lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson, 581 F.3d at 1316. The Federal Circuit has also held that the Board can favor competent medical evidence over lay statements offered by the Veteran if the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King v. Shinseki, 700 F.3d 1339, 1344 (2012). While the Board finds the Veteran competent to report his onset and disappearance of headaches, without evidence showing that he has the necessary medical knowledge, training, or expertise, he cannot competently opine that his headaches were associated with (or symptoms of) his sleep apnea in this particular case. See 38 C.F.R. § 3.159(a)(1), (2); Jandreau, 492 F.3d at 1377. The Veteran and the VA medical examiner each cited medical literature in support of their respective positions. Notably, each citation is broad. The Veteran generally cites the "AMA," which the Board takes to mean the American Medical Association, and he cites "recognized medical institutions." The VA examiner cited UpToDate. The Board finds the VA's examiner's opinion and rationale are more probative than the Veteran's assertions. First, the VA examiner is a neurology attending physician. Naturally, he has the necessary knowledge, skills, and training to make medical conclusions, and there is no evidence to the contrary. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (the competence of VA examiners is presumed absent evidence to the contrary). The Veteran does not possess any medical or other related qualifications. Thus, the Board gives more weight to the VA examiner's literature citation as it is more credible than the Veteran's citation because the Board believes the VA examiner has a better ability to analyze and interpret medical literature for its value and weed out literature that is not reliable. Second, although the examiner only generally referenced the UpToDate database in support of his opinion, an examiner is not required to "explicitly lay out [his] journey from the facts to a conclusion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2017). Moreover, VA examiners are presumed, absent clear evidence to the contrary, "to remain up-to-date on medical knowledge and current medical studies" and failure to cite any studies is not a basis for finding the examination report inadequate. Id. at 10607. The Veteran is not provided the same presumptions, and he has not offered sufficient evidence that he has acquainted himself with relevant medical studies. To the extent the examiner did not include any relevant medical studies or datajust as the Veteran did notthe adequacy of the medical opinion hinges on the rationale that bridges the gap between a clear conclusion and the supporting data. See Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) ("[A]n adequate medical report must rest on correct facts and reasoned medical judgment so as [to] inform the Board on a medical question and facilitate the Board's consideration and weighing of the report against any contrary reports."); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) ("[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two."). In this regard, the Board concludes that the January 2020 VA opinion is based on reasoned medical judgment and sufficiently informs the Board to facilitate its consideration of whether service connection is warranted. See Monzingo, 26 Vet. App at 107. The VA examiner reviewed the Veteran's entire claims file, to include his military medical and personnel records, private records, and lay evidence, and concluded that the Veteran's headaches were not a symptom indicating sleep apnea based on review of medical literature from UpToDate as there is no established cause-and-effect relationship. Therefore, the Board finds that the VA examiner's opinion, that the Veteran's in-service headaches did not constitute early symptoms of sleep apnea, is more probative than the Veteran's lay assertions to the contrary. As such, the evidence is against finding that the Veteran's in-service headaches were a symptom of his sleep apnea such that his sleep apnea had its onset in service. Conclusion In sum, the evidence of record is against finding that the Veteran's claimed in-service diet and sleep habits required by his duties; claimed in-service exposure to contaminants and/or carcinogens; claimed in-service residuals of malaria vaccination, including blood poisoning; claimed in-service exposure to asbestos; and claimed in-service onset of headaches represent in-service events, injuries, or illnesses for purposes of VA service connection in relation to his sleep apnea. There is sufficient evidence of in-service exposure to ionizing radiation to satisfy the requirement for an in-service event. Third element: A causal link The VA Regional Office obtained a VA medical opinion in accordance with the Board's January 2019 remand directive. As explained, the examiner reviewed the Veteran's entire claims file, including medical and lay evidence of record. The examiner opined that the Veteran's "sleep apnea was not caused by sleep apnea during active military service." Although the opinion is oddly worded, the Board understands it to mean that the Veteran's sleep apnea was not caused by his active military service. The examiner reasoned that there were no in-service symptoms suggestive of sleep apnea. The Veteran did not report any sleep issues during his June 1999 retirement examination. He was not diagnosed with sleep apnea until 11 years after separation from service. The examiner cited the Veteran's advancing age as a risk factor for development of sleep apnea. The examiner finally relied on his review of medical literature from UpToDate, which did not establish a cause-and-effect relationship between sleep apnea and exposure to ionizing radiation. The VA medical opinion is the only medical evidence of record addressing the etiology of the Veteran's sleep apnea. To the extent the Veteran asserts his sleep apnea is due to his exposure to ionizing radiation, he is not competent to make that medical conclusion as he does not have the necessary knowledge, skills, training, or experience to do so. See 38 C.F.R. § 3.159(a)(1), (2); Jandreau, 492 F.3d at 1377. Based on the absence of in-service symptoms of sleep apnea and the lack of a cause-and-effect relationship between sleep apnea and ionizing radiation, the Board finds the VA examiner's opinion credible and probative because it relied on accurate facts, considered the Veteran's relevant medical records, medical history, and lay statements, and provided a well-reasoned medical judgment. Therefore, the third element of service connection is not satisfied with respect to the Veteran's assertion that exposure to ionizing radiation caused his sleep apnea. In the interest of completeness, the examiner also reasoned that according to his review of medical literature from UpToDate, there is no established cause-and-effect relationship between sleep apnea and exposure to contaminants and/or carcinogens; residuals of malaria vaccination, including blood poisoning; nor exposure to asbestos. Thus, even if the Board were to assume only for the sake of argument that the Veteran did experience his claimed in-service events, the VA examiner's opinion is the most probative evidence of record, for the same reasons just discussed, addressing these factual claims in relation to the etiology of the Veteran's sleep apnea. As such, the evidence would weigh against finding a causal link among these claimed in-service events with the Veteran's sleep apnea. Conclusion Accordingly, service connection for sleep apnea is not warranted based on the claims of: (1) in-service diet and sleep habits required by his duties; (2) in-service exposure to contaminants and/or carcinogens; (3) in-service residuals of malaria vaccination, including blood poisoning; (4) in-service exposure to ionizing radiation; (5) in-service exposure to asbestos; and (6) in-service onset of headaches. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.