Citation Nr: 21068134 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 16-63 197 DATE: November 9, 2021 ORDER Service connection for sleep apnea as secondary to service-connected posttraumatic stress disorder with alcohol use disorder in sustained remission (PTSD) is denied. FINDING OF FACT Sleep apnea is not caused or aggravated by service-connected PTSD, to include medications taken for such disability. CONCLUSION OF LAW The criteria for service connection for sleep apnea as secondary to PTSD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1994 to June 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In his February 2018 substantive appeal (VA Form 9), the Veteran requested a Board hearing; however, he subsequently withdrew such request in February 2018 and January 2019 correspondence. In February 2020 and June 2021, the Board remanded the issue on appeal for additional development and it now returns for further appellate review. Entitlement to service connection for sleep apnea as secondary to service-connected PTSD. As an initial matter, the Board notes that the Veteran does not contend, nor does the record suggest, that his sleep apnea is related to service on a direct basis. In this regard, his service treatment records are negative for any complaints, treatment, or diagnosis referable to sleep apnea and he was initially diagnosed with such disorder in August 2006, which is almost 20 years after his separation from service. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to considered "all possible" substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Rather, the Veteran contends that his sleep apnea is caused or aggravated by his service-connected PTSD, to include medications taken for such disability. In this regard, service connection is established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). As indicated previously, the Veteran has a current diagnosis of central and obstructive sleep apnea as evidenced by an August 2006 sleep study. Additionally, he is service-connected for PTSD and, as part of the management of such disability, he takes Trazodone. Thus, the remaining inquiry is whether his sleep apnea is caused or aggravated by such disability, to include such medication. In this regard, in August 2017, a VA examiner opined that the Veteran's sleep apnea was less likely than not proximately due to, the result of, or aggravated by his PTSD; however, as the rationale for such opinion was based on an inaccurate factual premise, the Board remanded the claim in February 2020 in order to obtain an addendum opinion addressing such matter. In April 2020, a VA examiner reviewed the record, interviewed the Veteran, conducted a physical examination, and opined that his sleep apnea was less likely than not proximately due to, the result of, or permanently aggravated by his PTSD, or medications taken for such disability, to include Trazodone. In support thereof, she noted that the medical literature is silent for a causal relationship that PTSD or any medication taken to treat such disability, to include Trazodone, caused the development of sleep apnea or any change in the pathology of sleep apnea so as to cause permanent worsening. However, as a permanent worsening is not required to establish service connection based on aggravation of a nonservice-connected disability, the Board remanded the case in June 2021 in order to obtain an addendum opinion that applied the correct legal standard in addressing such inquiry. Thus, in July 2021, the April 2020 VA examiner again reviewed the record and opined that it is less likely than not that the Veteran's sleep apnea was aggravated by his PTSD, to include treatment with Trazodone. In support thereof, she noted that the medical literature did not support any pathophysiologic alterations to sleep apnea in adults. The examiner indicated that Trazodone would not cause or worsen sleep apnea. In this regard, she explained that studies showed that such medication lowers the threshold for awakening, when obstructive breathing occurs, but does not cause an increase in apnea, hypopnea, or obstruction. Further, while opiates and buprenorphine may cause central sleep apnea, Trazodone is not in either class of drugs. The Board affords great probative weight to the April 2020 and July 2021 VA examiner's opinions as such considered all of the pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); 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"). Notably, there is no medical opinion to the contrary. The Board also considered the Veteran's assertions as to the etiology of his sleep apnea; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such requires knowledge of the anatomy of the upper respiratory system, and the impact a psychiatric disability, or related medications, have on such system. Thus, such matter may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran's opinion as to the etiology of his sleep apnea is not competent evidence and, consequently, is afforded no probative weight. Therefore, based on the foregoing, the Board finds that sleep apnea is not caused or aggravated by service-connected PTSD, to include medications taken for such disability. Thus, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for sleep apnea as secondary to PTSD. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5017; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Breckenridge 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.