Citation Nr: 21066501 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-39 877A DATE: November 1, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), including as secondary to service-connected posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran's OSA is not directly related to service, or secondary to service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for OSA due to service or service-connected disabilities are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from November 1968 to August 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in March 2019 and September 2021. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Entitlement to service connection for obstructive sleep apnea (OSA), including as secondary to PTSD The Veteran contends that he is entitled to service connection for OSA as secondary to service-connected disabilities, specifically PTSD. Pursuant to the September 2021 Board remand directives, a medical opinion was obtained to address a submitted article and whether the Veteran's obstructive sleep apnea is at least as likely as not (50 percent probability or greater) caused or aggravated beyond its natural progression PTSD, including any treatment therefor. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2018); 38 C.F.R. § 3.303 (2018). A Veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). After review of all the lay and medical evidence of record, the Board finds that the evidence weighs against a finding of OSA during service. The Veteran's active-duty STRs do not reflect his complaints of, treatment for, or diagnosis of a sleep disorder. The Veteran's separation exam in June 1970 is negative for any snoring or sleep concerns. No submission made by the Veteran offers evidence about the onset or etiology of OSA on a direct basis. Therefore, as the second element (in-service incurrence) is not demonstrated with respect to OSA, the claim for service connection for OSA, must be denied on a direct basis. As no in-service incurrence is shown, the Board need not address whether there is a causal relationship between the present disorder and service (third element). Service connection may not be granted on a direct basis; however, the Veteran contends that his OSA may be secondary to his service-connected PTSD. Secondary service connection Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). The Veteran was diagnosed with OSA in June 2011. The first element of secondary service connection, a current disability is met. Next, he is service connected for PTSD. The second element of service connection on a secondary basis is also met. However, the third element, a medical nexus, must be resolved. As directed by the September 2021 Board remand, a VA examiner was asked to clarify the nature of the "chronic sleep impairment" as a symptom attributable to the Veteran's PTSD as documented in the December 2012 VA examination report. The October 2021 VA examiner explained that the Veteran's sleep disturbances are secondary to and subsumed under his PTSD and a representative symptom therein. The examiner referenced how anxiety and hypervigilance impair the Veteran's ability to fall and stay asleep. The examiner did not relate this "chronic sleep impairment" to OSA. See October 2021 VA examination. Next, the examiner clarified the diagnosis of a sleep disorder other than sleep apnea, including a REM sleep behavior disorder. The examiner stated, "REM sleep disorder is most likely related to his PTSD problems which do not allow him to relax during REM sleep. Neither affect OSA which is due to obstruction of the posterior pharynx." See October 2021 VA examination. Discussing the article submitted by the Veteran entitled, "Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort", the examiner stated that the referenced paper noted that patients with psychiatric disorders also have OSA. The examiner explained, "That does not mean that OSA is due to psychiatric disorder, however. Also, it does not mean that OSA causes a psychiatric disorder... OSA is due to obstruction of the posterior pharynx and no psychiatric disorder causes this." See October 2021 VA examination. The examiner also provided an opinion as to whether the Veteran's obstructive sleep apnea is at least as likely as not (50 percent probability or greater) aggravated beyond its natural progression by his service-connected PTSD, including any treatment therefor. The examiner noted a baseline level of severity in June 2011, and compared any aggravation to that baseline. The examiner concluded that the current severity of OSA is not greater than the baseline. The rationale is that the Veteran's OSA is the same. Essentially, the Veteran's condition can be made better if he uses a CPAP machine nightly all night, but his inability to do so has not made the condition worse. It was further stated, "All of the problems with using his cpap are due to his nightmares and other manifestations of his mental illness do not make the OSA worse. The patient could put his mask on when he takes his PTSD medication before he gets drowsy." See October 2021 VA examination. The October 2021 examiner's opinion that the condition claimed was less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected PTSD is highly probative because it was based upon a thorough review of the claims file, medical literature, an in-person examination, and a well-reasoned rationale. The Board finds this opinion to be factually accurate, fully articulated, and containing sound reasoning. A medical opinion that is factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board acknowledges the Veteran's belief that his OSA is the result of, or aggravated beyond its natural progression by his PTSD. However, his statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on questions of etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a layperson, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau, 492 F.3d 1372. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's sleep apnea condition and his military service, including no competent medical evidence establishing a link between OSA and active service on a direct or secondary basis, including due to his PTSD. Therefore, the Board finds that a preponderance of the medical evidence that is of record weighs against the claim for service connection for OSA. (Continued on the next page) For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Nelson, 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.