Citation Nr: 21072824 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 13-25 970 DATE: December 6, 2021 ORDER Entitlement to service connection for a right elbow disability is denied. Entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension with headaches, is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a right elbow disability began during active service or that a right elbow disability was otherwise related to an in-service injury, disease, or service-connected disability. 2. The preponderance of the evidence is against finding that sleep apnea began during active service or that sleep apnea was otherwise related to an in-service injury, disease, or service-connected disability, to include as secondary to obesity that was caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right elbow disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension with headaches, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1998 to September 2001. This matter comes before the Board on appeal from a February 2011 Regional Office (RO) rating decision. In November 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Service Connection Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, or results from, a service-connected disease or injury shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection on the basis of aggravation is permitted. 38 C.F.R. § 3.310(b). Compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for a right elbow disability is denied. The Veteran contends that he hyperextended his right elbow in service and that it has continued to bother him ever since. (See Board hearing transcript, pages 40-41.) He testified that his right elbow makes clicking sounds, swells, and prevents him from lifting heavy objects. He also stated that he experiences pain and weakness in the right elbow. (See Board hearing transcript, pages 40-42.) His service treatment records corroborate the occurrence of this injury. Specifically, the Veteran's service treatment records show that, in January 1999, he presented with complaints of right elbow pain for three days, which started after he hyperextended his right elbow while playing basketball. After a physical examination, triceps head tendonitis was assessed. The July 2001 separation examination report reflects that his upper extremities were clinically normal when examined. The July 2001 separation medical history report reflects that he expressly denied a history of, or current, painful elbow. Otherwise, the Veteran's service treatment records contain no complaints of, or treatment for, the Veteran's right elbow. This claim was remanded in March 2016 so that the Veteran could undergo a VA examination to determine whether a current diagnosis was warranted and to obtain an etiology opinion. The Veteran was afforded a VA examination in May 2016. The examiner concluded that the Veteran did not have a current diagnosis. The examiner noted triceps tendonitis resolved. The examiner noted that the Veteran has not had his right elbow evaluated since leaving active duty in 1999. The examiner noted that on examination he found insufficient medical documentation to make a diagnosis. The examiner stated that presently there is insufficient medical documentation to connect the right elbow condition, 1999 triceps tendonitis, to present elbow condition-symptoms. In December 2017, the Veteran submitted a December 2016 private treatment record that diagnosed radial collateral ligament sprain of the right elbow and that an MRI showed radial collateral ligament chronic partial tear, no loose bodies or osteochondral defects. The Board thus remanded this claim in February 2018 so the Veteran could undergo an examination to determine whether the Veteran has a current disability of the right elbow that is etiologically related to his in-service injury. The Veteran underwent a VA examination for his right elbow claim in June 2019. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed lateral epicondylitis (also known as "tennis elbow"). The examiner ultimately found that the Veteran's right elbow disability was less likely than not incurred in or caused by the claimed in service injury, event, or illness. In the rationale, however, the examiner suggested that the Veteran's acquired psychiatric disability was one of several factors that contributed to his right elbow disability. The examiner stated that the Veteran's service-connected posttraumatic stress disorder (PTSD) with depressed mood, anxiety, and sleep impairment is a contributing factor to his lateral epicondylitis of the right elbow. Specifically, the examiner stated that "The studies show that mental disorders and obesity are contributing factor[s] resulting in multiple site pain, smoking history, [and] repetitive physical activities [that] contribute to lateral epicondylitis." The examiner ultimately stated the following: The Veteran is a 45 years old male who actively works as a data analyst involving repetitive arm, elbow/hands movement, has a history of smoking[,] he quit in 2007, has posttraumatic service treatment disorder with depressed mood, anxiety and sleep impairment, has a long-standing obesity, the veteran's weight on the day of this exam is 262 pounds, height is 73 inches, the BMI [body mass index] is 34.6 indicating an obese BMI. The examiner also opined that there is no nexus between the in-service treatment in January 1999 and the current disability, noting that the in-service condition was acute and there was no evidence of chronicity. In its January 2020 remand, however, the Board noted that the examiner did not provide a basis for the conclusion that PTSD and obesity are contributing factors to the right elbow disability. The VA examiner did provide hyperlinks to abstracts and articles from the National Institutes of Health (NIH). The Board notes that none of these materials supports the principle of a relationship between psychiatric disorder and lateral epicondylitis. The abstract from the first article states that "Current smoking ... and former smoking ... were associated with definite lateral epicondylitis. An interaction ... was found between repetitive movements of the arms and forceful activities for the risk of possible or definite lateral epicondylitis...." This abstract does not mention psychiatric disability as a causal or aggravating factor in lateral epicondylitis. ("Prevalence and determinants of lateral and medial epicondylitis: a population study," https://pubmed.ncbi.nlm.nih.gov/16968862/ ) The abstract from the second article states that "Multivariate analysis showed that the risk factors associated with lateral epicondylitis were rotator cuff pathology ..., De Quervain's disease ..., carpal tunnel syndrome ..., oral corticosteroid therapy ..., and previous smoking history ...." It was also stated that "Diabetes mellitus, current smoking, trigger finger, rheumatoid arthritis, alcohol intake, and obesity were not found to be associated with lateral epicondylitis." Neither the abstract nor the article's text mentions psychiatric disability as a causal or aggravating factor in lateral epicondylitis. ("Risk factors in lateral epicondylitis (tennis elbow): a case-control study," https://pubmed.ncbi.nlm.nih.gov/22490998/) The abstract from the third article contains the following Conclusion: Fat mass, FMI [fat mass index], and BMI are associated with MSP [multisite pain] and pain at all lower-extremity sites and hand pain, independent of sociodemographic, physical activity, and psychosocial factors. This suggests that both loading and systemic inflammatory factors may have an important role in the pathogenesis of fat-related MSP. Neither the abstract nor the text of the article itself mentions psychiatric disability as a causal or aggravating factor in multisite pain. ("Associations Between Fat Mass and Multisite Pain: A Five-Year Longitudinal Study," https://pubmed.ncbi.nlm.nih.gov/27390162/) Neither the abstract nor the text of the fourth article itself mentions lateral epicondylitis. ("Pain, Nicotine, and Smoking: Research Findings and Mechanistic Considerations," https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202023/) In short, the June 2019 VA examiner suggested an etiological link between the Veteran's right elbow disability and his service-connected psychiatric disability, but provided no explanation or medical authority to support this assertion. In January 2020, the Board remanded this claim for an opinion with a rationale that addresses this particular theory of entitlement. The February 2020 VA examination report found that the right elbow disability is not related to the service-connected psychiatric disability. As a rationale, the examiner noted that "The claimed disorder is a separate entity entirely from the service connected condition and unrelated to it. The medical literature does not support a medical relationship. A nexus has not been established. [A]ny comorbidity between [service-connected disability] and [nonservice-connected] elbow [disability] are mere coincidence..." The examiner also found that the Veteran's right elbow disability was not at least as likely as not aggravated beyond its natural progression by the service-connected psychiatric disability. As a rationale, the examiner noted that "there is no anatomic or medical connection between [service-connected disability] and [nonservice-connected] claim." With respect to conflicting medical evidence, the examiner noted that "The elbow is completely separate for a NEXUS which should be a strong negative. [P]rior mention of such earlier appears to be a mistypo at the time on re[-]review." In April 2021, the Board found that a remand for an addendum opinion was necessary, as it was unclear which portion of the June 2019 examination report appears to be a typo. Thus, it was not clear to the Board whether the February 2020 VA examination report was clearly refuting the June 2019 VA examiner's assertion concerning a relationship between the Veteran's acquired psychiatric disability and his right elbow epicondylitis. A clarification of the examiner's "mistypo" reference was required, or, in the alternative, the examiner was requested to evaluate the substance of the June 2019 VA examination report. The author of the July 2021 addendum was not the author of the February 2020 VA addendum opinion. Thus, rather than attempting to determine what the extremely confusing reference to a "mistypo" signified, the examiner evaluated the substance of the June 2019 VA examination report and thus satisfied the April 2021 Board remand instructions. (The Board notes that, while the reference to a "mistypo" is unclear, the Board can find no reasonable interpretation of this statement that would probatively support finding a relationship between the Veteran's psychiatric disabilities and his right lateral epicondylitis.) With respect to causation, the July 2021 addendum opinion found that the Veteran's right elbow disability is not at least as likely as not proximately due to or the result of the Veteran's service-connected condition (acquired psychiatric disability). The examiner reviewed the record and provided an extremely thorough rationale that addresses the facts of the Veteran's case and pertinent medical principles. She defined "lateral epicondylitis," noting that it "'occurs when tendons in your elbow are overloaded, usually by repetitive motions of the wrist and arm." She defined "tennis elbow" as "'an overuse and muscle strain injury. The cause is repeated contraction of the forearm muscles that you use to straighten and raise your hand and wrist.'" She noted that "the repeated motions and stress of the tissue may result in a series of tiny tears in the tendons that attach to the forearm muscles to the bony prominence at the outside of your elbow." She noted that "'Many other common arm motions can cause tennis elbow, including Using plumbing tools, Painting, Driving screws, Cutting up cooking ingredients, particularly meat, and Repetitive computer mouse use.'" She also noted that age (in particular "in adults between the ages of 30 and 50"); occupation (particularly in "People who have jobs that involve repetitive motions of the wrist and arm," including "plumbers, painters, carpenters, butchers and cooks"); and certain sports (such as sports racket sports when an individual has poor technique) are relevant risk factors. With respect to the 2019 VA examination report's notation of a contributing factor between psychiatric disorders and obesity, the examiner noted that "the literature does not support [the proposition that] a mental health disorder or obesity affect the tendons of the elbow," and that "Contributing factors do not equate with causation." She noted that "Not all obese individuals get lateral epicondylitis and not all psychiatric disorders lead to lateral epicondylitis. A plausible secondary relationship is not established." The examiner cited specific relevant medical literature to support her conclusions. With respect to aggravation, the July 2021 addendum opinion also found that the Veteran's right elbow disability is not at least as likely as not aggravated beyond its natural progression by his service-connected condition (acquired psychiatric disability). The examiner found that "There is no objective evidence to support aggravation of the lateral epicondylitis by the acquired psychiatric disorder or the obesity." She noted that "The veteran's psychiatric disorder does not preclude all forms of exercise and there are multiple exercises that one can perform that does not involve the use of one upper extremity." She noted that "The claims folder supports the veteran being enrolled in the MOVE program and able to perform aerobic exercise. The claims folder also supports the ability to lose weight despite the acquired psychiatric disorder." She noted that "There is no objective evidence to support flare ups or exacerbations of the lateral epicondylitis due to the acquired psychiatric disorder or obesity," and that "No aggravation beyond natural progression is identified." She then listed the Veteran's weight at seven points in time between January 2008 and December 2015: His weight in January 2008 was 256 pounds; his weight in February 2009 was 270 pounds; his weight in May 2011 was 259 pounds; his weight in February 2012 was 266 pounds; his weight in April 2013 was 234 pounds; his weight in December 2014 was 260 pounds with a body mass index (BMI) of 33; and his weight in December 2015 was 236 pounds. The Board finds that the above June 2019 (direct) and July 2021 (secondary) VA examination report/addendum are highly probative to the case at hand. They were authored by individuals who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). The examination report is based on interview and examination of the Veteran, and the examination report and addendum opinion are based on review of the claims file. They address all theories of entitlement, including direct service connection and secondary service connection based on causation and aggravation. The rationales that are provided are thorough and contain discussion of the facts of the Veteran's case and pertinent medical principles with citation to pertinent medical literature. For these reasons, the Board finds that these opinions are highly probative to this claim. In particular, it finds that the July 2021 addendum opinion is highly probative to this claim, as it responds to the April 2021 opinion request and provides a detailed rationale that includes citation to the facts of the Veteran's case and pertinent medical principles. She responded to the June 2019 VA examiner's assertion that the Veteran's service-connected acquired psychiatric disability contributed to his lateral epicondylitis. As noted above, the June 2019 examiner stated that "The studies show that mental disorders and obesity are contributing factor[s] resulting in multiple site pain, smoking history, [and] repetitive physical activities [that] contribute to lateral epicondylitis." The 2021 examiner, however, explained the mechanism of injury that causes lateral epicondylitis (tennis elbow) and described multiple factors that lead to lateral epicondylitis. The examiner also noted that the medical literature does not support finding a relationship (either through causation or aggravation) between psychiatric disability and lateral epicondylitis. (As noted above, the June 2019 VA examination report itself provides neither explanation nor citation to literature that suggests otherwise.) Based on the above, the Board therefore finds that the evidence that weighs in favor of finding that an acquired psychiatric disability was a contributory cause to the Veteran's right lateral epicondylitis is less probative than the evidence that weighs against finding such a relationship. The only remaining opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the question of whether there is a medical link between an acquired psychiatric disability and his current right elbow disability, or a relationship between a current right elbow disability and an in-service injury, is of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In short, the Board finds that entitlement to service connection for a right elbow disability, either on a direct basis or as secondary to a service-connected disability, is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 2. Entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension with headaches, is denied. The Veteran has claimed entitlement to service connection for sleep apnea. He contends that this disability began during service. (See Board hearing transcript, page 108.) Alternatively, he contends that this disability is related to his service-connected hypertension with headaches. (See December 2015 personal statement.) At his hearing, the Veteran testified that he did not sleep much during service and would sometimes stay up several days in a row. (See Board hearing transcript, page 108.) His wife described his sleep during service as follows: [W]hen he was finally able to sleep, he would stop breathing, and it would be for long periods of just silence, 45 seconds or more, and his body would begin to tremble, and you could feel his heart speeding up, and he would fight and gasp for air. And then it would wake him. (See Board hearing transcript, page 109.) She finally convinced the Veteran to have a sleep study and he was diagnosed with sleep apnea; his CPAP machine did not help, and he underwent surgery for a deviated septum. (See Board hearing transcript, page 110.) She noted that, following weight loss, his sleep apnea is still present but not as bad. (See Board hearing transcript, page 110.) With respect to the secondary service connection claim, the Veteran's wife testified that the Veteran gained a lot of weight from his hypertension medication. (See Board hearing transcript, page 109.) The Veteran's representative noted that the Veteran has lost weight, but the sleep apnea is still present. (See Board hearing transcript, page 110.) The Veteran's service treatment records contain neither complaints of nor treatment for symptoms associated with sleep problems or sleep apnea. On his July 2001 separation medical history report, the Veteran expressly denied any history of, or current, frequent trouble sleeping. A February 2009 VA medical record notes that the Veteran had been referred for a sleep study in January 2008 but that the appointment was cancelled because the Veteran had moved away from town. The Veteran underwent a sleep study in March 2009, and an April 2009 VA medical record notes that "This study is consistent with supine REM-related sleep apnea syndrome. A trial of CPAP is indicated." A May 2016 VA neurology outpatient note contains a medical history. It notes that the Veteran was diagnosed with mild obstructive sleep apnea following a March 2009 polysomnogram. He was given a CPAP, which has been helpful. It was noted that he had surgery for a deviated septum in 2014 and now no longer uses a CPAP. It was noted that he no longer has daytime fatigue and no longer snores consistently. The Veteran underwent VA examinations in May 2016 and May 2017, and an addendum opinion was obtained in February 2017. The May 2016 VA examination report notes a diagnosis of obstructive sleep apnea and opines that the Veteran's sleep apnea is less likely than not proximately due to or the result of his service-connected hypertension with headaches. The examiner's rationale was that obstructive sleep apnea bears no cause-effect relationship with hypertension with headaches. In February 2017, VA obtained a physician's opinion concluding that the Veteran's obstructive sleep apnea is less likely than not due to service-related events. As a rationale, the examiner noted that the Veteran was in service until 2001 and was not diagnosed with his mild obstructive sleep apnea until 2009, which is almost eight years after service. It was noted that the Veteran has been diagnosed with a history of narcolepsy and that his in-service symptoms, such as not sleeping for almost 72 hours, are a sign of narcolepsy or another problem relating to sleep or health, but not to obstructive sleep apnea. In May 2017, VA obtained an addendum opinion. Based on review of the record, the examiner concluded that the Veteran's sleep apnea diagnosis is less likely as not incurred in or caused by service, nor is it proximately due to or the result of service-connected hypertension with headaches (including medication taken for this condition), nor is it aggravated beyond its natural course by service-connected hypertension with headaches (including medication taken for this condition). As a rationale, the examiner noted that review of the claims file reveals no medical entries in the Veteran's service treatment records for complaints suggestive of a primary sleep disorder consistent with sleep apnea. The examiner noted that obstructive sleep apnea was diagnosed nearly eight years after active duty. Obstructive sleep apnea is characterized by recurrent collapse of the velopharyngeal and/or oropharyngeal airway during sleep, resulting in substantially reduced or complete cessation of airflow despite ongoing breathing efforts. He noted that the pathophysiologic mechanism is distinct from the pathophysiology of either headaches or hypertension. He stated that a medical review of the medications that were noted in the Veteran's history using UPTODATE finds no causal relationship with their use and the development of sleep apnea. He noted that he "would have to resort to mere speculation to comment on whether the Veteran's service-connected hypertension with headaches, including medications for treatment, aggravated beyond the natural course of the Veteran's OSA [obstructive sleep apnea] diagnosed in 2009." This claim was remanded in January 2020 to obtain an opinion with respect to whether the Veteran's obesity was caused by his service-connected hypertension with headaches, including medications for treatment. If such a relationship was found, the examiner was asked whether the obesity/weight gain was a substantial factor in causing sleep apnea. If such a relationship was found in response to this second prompt, the examiner was asked whether the sleep apnea would have not occurred but for the obesity/weight gain caused by the service-connected hypertension with headaches, including medications for treatment. Pursuant to the Board's January 2020 Remand, a VA opinion was provided in February 2020. The February 2020 VA examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. In his rationale, the examiner noted that the service-connected conditions cannot cause the Veteran to gain weight and that there is no direct or indirect relationship between the claim and service-connected conditions. He cited a recent Journal of Obesity article and majority opinion in UPTODATE that notes that many conditions are associated with obesity and that BMI is a corollary of certain conditions. However, the article noted that available data cannot confirm that BMI caused the diseases. It also noted that other factors often partially or fully explain links to BMI and health, including exercise, nutrition, insulin resistance, and weight stigma. It further noted that obesity can increase risk but cannot be shown to have causality. Finally, it noted that genetic and involuntary environmental contributions to body weight outweigh voluntary lifestyle choices. The claim had to be remanded to ensure compliance with a United States Court of Appeals for Veterans Claims (Court) precedential opinion that was issued on February 24, 2020, after the Board's remand. In Walsh v. Wilkie, 32 Vet. App. 300 (2020), the Court held that "the Board clearly erred in relying on a medical opinion that did not adequately address whether the secondary service connection was warranted based on a theory that the veteran's obesity was aggravated by her service-connected conditions since it focus[ed] on direct causation and was silent on the question of aggravation of obesity." The Court addressed "G.C. Precedent Opinion 1-2017" (VAOPGCPREC 1-2017), noting that it "does not mention the concept of aggravation in the portion that discusses obesity as an 'intermediate step' and references only subsection (a) of 38 C.F.R. § 3.310. Nevertheless, the principles contained in § 3.310 make any distinction in G.C. Opinion 1-2017 between causation and aggravation legally untenable." Walsh, 32 Vet. App. at 305. The Court maintained that "[d]espite the G.C. opinion's silence regarding aggravation, the Board, in accordance with § 3.310(b), must consider aggravation in this context when the theory is explicitly raised by the veteran or reasonably raised by the record." Id. at 307. An etiology opinion was obtained that addresses these concerns in July 2021. Based on review of the record, the examiner opined that "It is less likely as not that the AGGRAVATION of weight gain/obesity as a result of service-connected hypertension with headaches, including medications for treatment, was a substantial factor in causing obstructive sleep apnea." She also opined that "It is less likely as not that obstructive sleep apnea would have occurred but for weight gain/obesity AGGRAVATED by the service-connected hypertension with headaches, including medications for treatmen[t]." In her rationale for both opinions, the examiner noted that "There is no objective evidence to support aggravation of the veteran's weight gain by the hypertension with headaches or medications used for the said condition." She noted that his "hypertension with headaches or medication does not preclude all forms of exercise and there are multiple exercises that one can perform with hypertension." She noted that "The claims folder supports the veteran being enrolled in the MOVE program and able to perform aerobic exercise." She noted that "The claims folder also supports the ability to lose weight despite the hypertension wit[h] headaches and medication (ace inhibitor, calcium channel blocker and HCTZ) for condition." She further noted that there was "No aggravation beyond natural progression identified by the hypertension with headaches and treatment for condition." She listed the weight and date figures that were noted in the right elbow disability claim, listed above. She then stated that "Aggravation was not proven after review of the claims folder to include BVA remand, prior DBQ's/MO's." She noted that "Not all obese individuals have OSA, and thin individuals can have this disease as well. Obesity can increase risk, but cannot be shown to have CAUSALITY for OSA." She cited a "2020 Journal of Obesity and a large majority opinion in UPTODATE literature search." The Board finds that the above examination reports and addenda are highly probative to the case at hand. They were authored by individuals who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). The examination reports are based on interview and examination of the Veteran, and the examination reports and addendum opinions are based on review of the claims file. They address all theories of entitlement, including direct service connection and secondary service connection based on causation and aggravation. They consider the roll of obesity, based on both causation and aggravation. The rationales that are provided are thorough and contain discussion of the facts of the Veteran's case and pertinent medical principles with citation to pertinent medical literature. For these reasons, the Board finds that these opinions are highly probative to this claim. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim (including diagnosing sleep apnea and finding a relationship based on causation or aggravation between his sleep apnea and service-connected hypertension and headaches) are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In short, the Board finds that entitlement to service connection for sleep apnea on a direct basis based on causation or aggravation, or on a secondary basis based on causation or aggravation, to include with an intermediate factor of obesity, is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, 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.