Citation Nr: 21065161 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 20-10 216 DATE: October 25, 2021 ORDER Service connection for obstructive sleep apnea (OSA) as secondary to posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT OSA was neither caused nor worsened beyond the natural progression by service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for OSA as secondary to PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant, had active service from July 1982 to September 2002. In an April 2020 decision, the Board denied service connection for OSA. The Veteran appealed the Board's denials to the United States Court of Appeals for Veterans Claims (Court or CAVC). The Board's decision was vacated pursuant to a Joint Motion for Remand (Joint Motion or JMR) on the bases that the Board relied on an inadequate September 2018 VA medical opinion because the examiner did not address whether service-connected PTSD aggravated OSA. In July 2021, the Board remanded the appeal for a VA medical opinion addressing the questions that included whether OSA was aggravated by service-connected PTSD. The Board directed the VA reviewer to schedule an examination if it was necessary to provide the requested opinion. In August 2021, an adequate VA medical opinion addressing whether OSA was caused or aggravated by PTSD based on review of the record was obtained; therefore, there has been compliance with the prior remand directive. The Veteran has argued that the VA medical opinions were inadequate because they were not based on an in-person examination; however, no in-person examination is needed to provide an adequate medical opinion in this case. The diagnosis of OSA is not in dispute. The only question is whether OSA was either caused or aggravated by PTSD. The VA medical opinions obtained in connection with the appeal were informed by known medical principles and knowledge of the particular facts presented in this Veteran's case as documented in the record, to include the course of diagnosis and treatment for OSA. When formulating the VA medical opinions, the VA reviewers considered the pertinent lay and medical evidence and histories of record, including the Veteran's service treatment records and post-service treatment records, the Veteran's lay statements and reported histories and symptoms, and medical articles submitted by the Veteran and/or the attorney. The Veteran has not suggested that when providing the medical opinions the VA reviewers should have considered any additional information that was not already of record, nor has the Veteran explained how an in-person physical examination could provide additional pertinent findings or information to VA reviewers in relation to the appeal, especially in this case where the history, findings, and diagnosis of OSA are established. The VA reviewers have medical training and expertise and did not indicate that an in-person examination was needed to provide an adequate medical opinion. The VA medical opinions are supported by adequate rationale. For these reasons, the Board finds that the collective VA medical opinions are adequate. The service connection claim for OSA was filed as a Fully Developed Claim (FDC) pursuant to the Secretary of VA's program to expedite claims. Under this framework, a claim is submitted in a "fully developed" status, limiting, if not eliminating, the need for further development by VA. As part of the FDC process, a veteran is to submit all evidence relevant and pertinent to the claim; however, under certain circumstances, additional development may still be required prior to adjudication of the claims. This additional development may include obtaining additional records and/or providing a VA medical examination. In this case, the complete service treatment records and all identified post-service treatment records are associated with the record. VA medical opinions based on review of the record and supported by adequate rationale were obtained in September 2018 and August 2021. Numerous medical articles were also submitted by the Veteran and considered in adjudicating the appeal. No further development is indicated. Service Connection Legal Authority Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may 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). Service connection may be established on a direct basis when there is competent, credible evidence of: (1) a current disability; (2) a disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. 38 C.F.R. § 3.303(a), (d). Service connection may be established on a presumptive basis for chronic diseases listed under 38 C.F.R. § 3.309(a) if chronic symptoms of the disease were shown in service; the disease was manifested to a compensable degree with a presumptive period, usually one year after service separation; or continuous symptoms of the disease were manifested since service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.33(b), 3.307, 3.309(a); see also Walker v. Shinseki, 708 F. 3d 1131 (Fed. Cir. 2013). Because the current diagnosis of obstructive sleep apnea is not listed as a chronic disease under 38 C.F.R. § 3.303(b), the presumptive service connection provisions are not applicable. Service connection may be established on a secondary basis for a disability which was either: (1) caused by, or (2) aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Compensation based on secondary aggravation will be awarded only for the degree of disability over and above the degree of disability prior to aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). Service Connection Analysis for Sleep Apnea The Veteran contends that the current sleep apnea, which was diagnosed many years after service retirement, was either caused or worsened beyond the natural progression by the service-connected PTSD. This is the sole contention and theory of entitlement to service connection for OSA; therefore, the analysis below is focused solely on the theory of secondary service connection, the only theory of entitlement that has been advanced by the Veteran and raised by the record. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009); see also March 2020 statement from the attorney (noting that the Veteran never claimed sleep apnea or direct basis). After review of all the lay and medical evidence of record, the Board finds that the weight of the lay and medical evidence of record is against finding that sleep apnea was either caused or worsened beyond the natural progression by service-connected PTSD. There is no medical opinion evidence of record suggesting a link between the current sleep apnea to the service-connected PTSD on either a causation or aggravation basis. Rather, the competent medical opinion evidence, supported by a rationale, shows no causal or aggravation relationship between service-connected PTSD and sleep apnea. In a September 2018 VA addendum opinion, the VA reviewer opined that it was less likely than not that OSA was proximately due to or the result of the service-connected PTSD. In support of the medical opinion, the VA examiner explained that OSA was caused by a structural defect in the upper airway. In October 2018, the Veteran asked a treating VA primary care physician to provide a medical opinion in support of the claim that PTSD either caused or aggravated OSA and sent two medical articles showing correlations between PTSD and depression and increased rates of sleep apnea. In response, the treating VA physician sought an opinion from the sleep clinic and told the Veteran that the sleep clinic would be better equipped to provide an accurate opinion. Later that month, a VA physician with the sleep clinic replied to the treating VA physician's request and ultimately stated a causal relationship between OSA and PTSD could not be concluded. In support of the medical opinion, the VA sleep clinic physician explained an association between OSA and PTSD had been a question since a study originated in 2010. The VA sleep study physician referenced the study submitted by the Veteran and stated that it was thought-provoking, led to subsequent studies about the association between PTSD and OSA, used the Berlin questionnaire to predict the risk of OSA, was not confirmed by sleep study, was among combat-related veterans, and found that it was much higher among younger veterans with PTSD. The VA sleep clinic physician noted that, due to the nature of the study, it was unable to be concluded that a causal relationship existed between PTSD and OSA. The VA sleep clinic physician wrote that, based on the studies to date, no causal relationship could be concluded but such studies had speculated that sleep deprivation and fragmentation interacting with physical and psychological stresses from PTSD could predispose persons to have OSA, but longitudinal studies were needed to develop such a conclusion. Subsequently, in October 2018 secure messaging correspondence, the treating VA physician informed the Veteran that she had heard from the sleep clinic, which advised assessment through a VA examination to determine service connection for sleep apnea. The treating VA physician also explained that the VA sleep clinic physician had referenced several studies noting an association between PTSD and sleep apnea but stated that there was not enough evidence from the studies to date to conclude a causal relationship. In an August 2021 addendum VA medical opinion, a VA reviewer opined that it was less likely than not that OSA was the result of PTSD or has been aggravated beyond its natural course due to any cause, including PTSD. When providing rationale for the medical opinion, the August 2021 VA reviewer wrote that any reports of snoring, daytime fatigue and somnolence, fitful sleep, insomnia, easy awakening, movements during sleep, gasping, and choking, etc. represented generalized symptoms with various potential causes and do not substantiate the diagnosis of OSA. The August 2021 VA reviewer opined that there was no nexus established in service or proximate to service, so it was less likely than not that OSA had a nexus to service. The August 2021 VA reviewer wrote that the service separation examination was clearly negative for frequent trouble sleeping, which was the hallmark of OSA. The August 2021 VA reviewer noted that the Veteran was not diagnosed with mild OSA until the sleep study in 2018 and stated that the apnea hypopnea index (AHI) was only 7.9 but with 02 desaturation, which suggested a recent onset of OSA because the AHI almost certainly would have been much higher had the condition arisen 16 years earlier. The August 2021 VA reviewer noted that it was established medical knowledge and practice that psychological comorbidities, including depression, PTSD, and anxiety (posttraumatic stress disorder with alcohol use disorder and major depressive disorder, recurrent, moderate), do not cause or aggravate OSA. The August 2021 VA reviewer wrote that, although sleep disturbances such as insomnia were common with psychological conditions, they were mediated by the central nervous system and differ from the mechanism of OSA. The August 2021 VA reviewer explained that OSA was due to upper airway obstruction associated with apneic episodes, and there was no physiologic or anatomic mechanism by which psychological conditions can cause or aggravate OSA, including the medications used to treat related psychological comorbidities. The August 2021 VA reviewer noted that sleep aids or sleeping pills, anti-anxiety medications, and antidepressants, etc. may cause sedation but do not cause or aggravate the mechanism of OSA. The August 2021 VA reviewer wrote that the medication effects could be ameliorated by discontinuing the medications or adjusting the dosage, which did not constitute aggravation of the baseline OSA condition. The August 2021 VA reviewer noted that there was no evidence of aggravation of OSA beyond its natural course due to any cause. The August 2021 VA reviewer explained that OSA tended to progress over time and often required CPAP adjustments or changes in treatment modality. The August 2021 VA reviewer noted that studies had suggested a possible association between OSA, PTSD, depression and anxiety but cause and effect, including aggravation, had not been established in the current, widely accepted, peer-reviewed medical literature. The August 2021 VA reviewer noted that the review included UpToDate, which was a respected, professional medical resource. The August 2021 VA reviewer wrote that the Veteran's cited articles did not establish cause, aggravation, or even the status as a risk factor. The August 2021 VA reviewer wrote that the impetus of both articles indicated avenues for possible future study and the importance of screening individuals with psychological comorbidities for OSA, so it was less likely than not that OSA was due to or incurred in the Veteran's depression, anxiety or related psychological comorbidities. The August 2021 VA reviewer opined that it was less likely than not that OSA has been aggravated beyond its natural course due to any cause, including the Veteran's related psychological comorbidities. The August 2021 VA reviewer noted that the rationale also applied to medications used to treat the psychological comorbidities (and alcohol), as to both cause and aggravation. The August 2021 VA reviewer noted that the studies cited discussed the possible association between psychological comorbidities and OSA and wrote that the authors drew no conclusion as to cause or aggravation. The August 2021 VA reviewer wrote that it has yet to be established that PTSD, depression, anxiety, and psychological comorbidities caused or aggravated OSA nor has their status as a risk factor been established. The August 2021 VA reviewer added that the Veteran reported in February 2020 that he used CPAP only 5 to 6 nights a week, and no aggravation of OSA can be inferred in the absence of compliance with prescribed treatment. The August 2021 VA reviewer noted that the AHI and diagnosis implied minimal pressures in the 6 to 9 range would have been applied to CPAP. Because the September 2018 and August 2021 VA reviewers have medical training and expertise as physicians, had accurate and adequate data on which to base the medical opinion, confirmed review of the record including the medical articles submitted by the Veteran, and provided adequate rationale for the medical opinions, the collective September 2018 and August 2021 VA medical opinions are of significant probative value. There is no medical opinion to the contrary of record. Although the Veteran has asserted that sleep apnea was caused or aggravated by service-connected PTSD, he is a lay person and, under the specific facts of this case showing post-service onset of symptoms and diagnosis of sleep apnea years after service, does not have the requisite medical training or credentials to be able to render an opinion regarding the cause of his sleep apnea. The etiology of the Veteran's sleep apnea is a complex medical etiological question dealing with the origin and progression of the respiratory system; sleep apnea is a disorder diagnosed primarily on symptoms, clinical findings, and physiological testing; and would require knowledge of a complex interaction or relationship between the different body systems, i.e., the physical (respiratory) disorder of sleep apnea with the psychological impairments of PTSD. See Waters v. Shinseki, 601 F.3d 1274, 1277-1278 (Fed. Cir. 2010) (recognizing similarly the complexity of a nexus between a psychiatric disorder and a physical disorder). While the Veteran is competent to report respiratory symptoms that he experiences at any time, under the facts of this case, he is not competent to opine on whether there is a link between sleep apnea, symptoms of which were manifested many years after service, and the service-connected PTSD (causation or aggravation) because such opinions require specific medical knowledge and training. For these reasons, the Veteran's unsupported lay assertion of secondary nexus is of no probative value. Numerous medical articles discussing an association between OSA or sleep-disordered breathing and various mental disorders were submitted by the Veteran in support of the appeal; however, none of the articles establishes that OSA can either be caused or aggravated by PTSD. For example, the February 2021 article entitled the Connection Between Sleep Apnea and PTSD, in pertinent part, relates that individuals with more severe OSA were more likely to have more severe PTSD, and for each clinically significant increase in PTSD symptom severity, a veteran's risk of OSA increased by 40 percent; however, the authors noted that the existence of a causal relationship between PTSD and OSA was uncertain. The 2015 article entitled Sleep-Disordered Breathing in Patients with Post-traumatic Stress Disorder reads that there is an association between PTSD and sleep-disordered breathing but the exact mechanism linking PTSD to sleep-disordered breathing was not fully understood. Another 2015 article entitled Obstructive Sleep Apnea in Severe Mental Disorders considered the prevalence of OSA in the mentally ill population but did not consider whether a mental disability either caused or aggravated OSA. The 2009 article entitled the Frequency and Predictors of OSA among Individuals with Major Depressive Disorder and Insomnia notes that study findings indicated that the frequency of OSA was higher among individuals with co-morbid MDD and insomnia and noted that previously identified predictors of OSA (male gender, older age, and high BMI) also applied to the study population; however, the authors did not indicate that a mental disability caused or aggravated OSA. The 2019 article entitled Prevalence and Correlates of Sleep Disorder Symptoms in Psychiatric Disorders relates that the findings of the study showed that symptoms of sleep disorders were not uncommon in psychiatric patients; however, the authors did not indicate that a mental disability caused or aggravated OSA. Similarly, the remaining medical articles on OSA and PTSD and/or psychiatric disorders show no causal or aggravation relationship between OSA and psychiatric disorders, including PTSD. Rather, they only show OSA prevalence may be increased in individuals with PTSD. Thus, the medical articles are of limited probative value and are outweighed by the case-specific VA medical opinions discussed above with rationale supporting the conclusion that PTSD did not cause or aggravate OSA. (Continued on the next page) Thus, the weight of the evidence is against a finding that sleep apnea was caused or worsened beyond the normal progression by the service-connected PTSD. In consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the appeal of service connection for sleep apnea as secondary to PTSD; consequently, the appeal must be denied. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Palmer, 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.