Citation Nr: A21018009 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 200924-110044 DATE: November 9, 2021 ORDER Entitlement to service connection for obstructive sleep apnea, as secondary to posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The Veteran's obstructive sleep apnea is caused by or is the result of her service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for obstructive sleep apnea, as secondary to PTSD, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the U.S. Navy from March 1990 to February 1995. The Appeals Modernization Act (AMA) creates a new framework for Veterans dissatisfied with Department of Veterans Affairs' (VA) decision on their claim to seek review. The AMA became effective on February 19, 2019. 38 C.F.R. § 3.2400(a)(1). The AMA applies to all initial decisions issued after February 19, 2019. The present matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2020 rating decision issued by VA Agency of Original Jurisdiction (AOJ). Accordingly, the decision is subject to the AMA. The Veteran timely appealed this rating decision to the Board in a September 24, 2020 VA Form 10182 Notice of Disagreement. The Veteran requested the direct review lane, which limits the Board's review to evidence of record at the time of the September 2020 rating decision. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of 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 granted on a secondary basis when the evidence establishes (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512; 38 C.F.R. § 3.310. Service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he or she served, his or her medical records, and all pertinent medical and lay evidence. See 38 C.F.R. § 3.303 (a); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) and Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). 1. Entitlement to service connection for obstructive sleep apnea secondary to posttraumatic stress disorder (PTSD) The Veteran maintains that her obstructive sleep apnea is caused by her service-connected PTSD. The Board agrees and finds that the elements of service connection on a secondary basis have been established. With respect to current disability, the record reveals that the Veteran was diagnosed by sleep study with obstructive sleep apnea in June 2016. Accordingly, the Board finds that a current disability has been established. The remaining question is whether the Veteran's obstructive sleep apnea was either caused by or aggravated by her service-connected PTSD. The record contains numerous positive and negative medical opinions addressing this question. In February 2020, a VA examiner concluded that the Veteran's obstructive sleep apnea is less likely than not cause by or the result of the Veteran's service-connected PTSD. However, the examiner cited to a medical journal article supporting the opposite conclusion. This article notes that a critical review of the literature supports an association between PTSD and sleep disordered breathing in both combat-related and non-combat-related PTSD. Furthermore, the examiner only cited to this article and did not address the Veteran's lay statements in reaching his opinion. Accordingly, the Board finds that the examiner's opinion is inadequate and has no probative weight. However, the Board affords some probative weight to the treatise evidence cited to by the examiner, as it directly addresses the relationship of PTSD to obstructive sleep apnea. Treating records also include a notation from a doctor in July 2020, who concluded that sleep apnea is a physical condition that is not caused by PTSD. However, this doctor provided no rationale to support his conclusion. Furthermore, the medical literature cited to by the April 2020 psychologist indicates that there is indeed a relationship between the two. Accordingly, the Board finds that this opinion is inadequate and affords it no probative weight. Additionally, a September 2020 VA examiner offered a negative nexus opinion on the basis of direct service connection. However, the examiner did not offer an opinion as to whether the Veteran's obstructive sleep apnea is caused by or aggravated by her service-connected PTSD. Accordingly, the Board finds that this opinion is inadequate and affords it no probative weight. Contrary to these opinions, a private psychologist offered a positive opinion in April 2020. The psychologist concluded that the Veteran's sleep apnea more likely than not is related to her service-connected PTSD. In support of this conclusion, the psychologist cited to peer-reviewed scientific studies showing a connection between anxiety, PTSD, and sleep apnea. Additionally, the psychologist indicated that the Veteran is positive for only two predisposing risk factors for sleep apnea, being African American and obese. Ruling out other factors for obstructive sleep apnea, such as gender and medical history of deviated septum, stroke, congenital deformity, or chronic diseases of the nose, the psychologist concluded that it is more likely than not that the Veteran's obstructive sleep apnea is caused by her PTSD. This opinion is thorough and is supported by a complete rationale. It was based on an interview with the Veteran, a review of her medical records, and a review of the medical literature. Accordingly, the Board finds that it is highly probative and affords it significant weight. Another positive opinion was offered by a private psychiatrist in August 2020. This psychiatrist concluded that that the Veteran developed obstructive sleep apnea due to two phenomena. First, she noted that PTSD itself leads to disrupted sleep architecture, promotes sleep disordered breathing, and causes neurophysiological changes within the body. Second, she indicated that the Veteran's obesity with progressive weight gain has played a role in the development of obstructive sleep apnea. With respect to the former, she noted that PTSD causes nightmares and disorder breathing during sleep and having the condition itself has led to physiological changes in the Veteran that developed into obstructive sleep apnea. Additionally, the psychiatrist cited to peer-reviewed scientific studies that supports a connection between PTSD and obstructive sleep apnea. This opinion is thorough and is supported by a complete rationale. It was based on an interview with the Veteran, a review of her medical records, and a review of the medical literature. Accordingly, the Board finds that it is highly probative and affords it significant weight. In sum, the most probative evidence of record, the two private positive opinion and medical literature cited to by the February 2020 VA examiner and two private doctors, demonstrates that the criteria for entitlement to service connection for obstructive sleep apnea secondary to the Veteran's PTSD have been established. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Beech, 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.