Citation Nr: 21073887 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 20-13 930 DATE: December 13, 2021 ORDER Service connection for insomnia is granted. Service connection for sleep apnea is granted. FINDINGS OF FACT 1. The Veteran's insomnia is proximately due to his service-connected posttraumatic stress disorder (PTSD). 2. The Veteran's sleep apnea is aggravated by his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for insomnia as secondary to service-connected PTSD are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for sleep apnea as secondary to service-connected PTSD are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1951 to October 1953. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in April 2020 and October 2020 for further development, which has been completed. The issues of entitlement to service connection for right and left foot disabilities, and right and left leg disabilities were also remanded. By way of a November 2020 rating decision, the RO granted service connection for bilateral pes planus (flat feet). By way of an October 2021 rating decision, the RO granted service connection for a right knee strain and degenerative arthritis (limitation of extension), a left knee strain and degenerative arthritis (limitation of extension), and a left knee strain and degenerative arthritis (limitation of flexion). The granting of service connection constitutes complete grants of these claims. Consequently, the issues are no longer before the Board. Additionally, in April 2020, the Veteran appealed the issues of entitlement to an increased rating and earlier effective date for PTSD, entitlement to service connection for hypertension, entitlement to increased ratings for hearing loss, and entitlement to a total disability rating based on individual unemployability (TDIU). These issues are part of a separate appeal stream and were adjudicated separately. SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran underwent a VA examination in May 2021. The examiner found that it was at least as likely as not that the Veteran's insomnia was caused by his sleep issues during service, as well as depression, anxiety, and PTSD. The examiner found that the current examination findings reflect that the Veteran continues to meet the criteria for insomnia. The examiner cited an October 2018 Disability Benefits Questionnaire (DBQ) in which PTSD and daytime fatigue were found to be due to insomnia. She also noted a June 2012 treatment report which noted flashbacks and dreams of Korea. Evidence weighing against the claim includes a November 2020 VA opinion in which the examiner declined to diagnose the Veteran with a sleep disability, and instead stated that sleep impairment was subsumed under the diagnosed PTSD. Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). In this case, there are no adequate reasons or bases to adopt one medical opinion over the other. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for insomnia is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board notes that for rating purposes, the symptoms of insomnia may be subsumed into the Veteran's rating for PTSD. Notwithstanding, given the May 2021 VA examiner's separate diagnosis of insomnia and her opinion that it is due to PTSD, service connection is warranted. Service connection for sleep apnea is granted. The Veteran submitted a March 2020 (DBQ) in which a private clinician opined that the Veteran's PTSD, and medications used to treat PTSD, have caused and continue to permanently aggravate the Veteran's sleep apnea. The examiner noted that an October 2018 VA psychiatric examiner found the Veteran to have angry outbursts, hypervigilance, sleep disturbance, depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The March 2020 clinician cited research reflecting that PTSD and other psychiatric disorders are commonly associated with sleep apnea. She stated that a recent study found that arousal-based mechanism initiated by posttraumatic stress promotes the development of sleep apnea in trauma survivors. The study found that with CPAP treatment, both sleep apnea and PTSD symptoms decreased, providing further evidence of the comorbidity of these conditions. She also noted that research has also shown that antidepressants affect sleep. The Veteran has been prescribed Escitalopram and Sertraline. These medications are selective serotonin reuptake inhibitor antidepressants (SSRI). Research shows that treatment with an SSRI may produce or exacerbate problems with sleep disturbance. Weighing against the claim is an April 2020 VA opinion in which a VA examiner opined that sleep apnea was less likely than not caused or aggravated by the Veteran's service connected PTSD. The examiner noted that the Veteran had a nocturnal polysomnogram conducted at the Biloxi VAMC in February 2015. It demonstrated an apnea hypopnea index (AHI) of 13.4 events per hour, which was aggravated by REM sleep stage (AHI of 37.2), with an oxygen saturation nadir to 83 percent. Most events were hypopneas, and no events were noted while the Veteran was sleeping in the prone position. He was considered to have "mild" obstructive sleep apnea, and he was advised not to sleep in the supine position and to elevate the head of his bed. The examiner noted that at the time of the study, the Veteran was 83 years old, and was obese (BMI was 31.1). The examiner noted that the most common causes of sleep apnea are older age, and obesity. The examiner stated that "although sleep disorders, including [obstructive sleep apnea] are associated with behavioral health disorders such as PTSD, this is not a causal relationship." The examiner believed that the March 2020 private clinician "seems to have conflated the symptoms of the Veteran's behavioral health disorder, his service connected PTSD, with the pathophysiology of [obstructive sleep apnea]." Finally, the examiner stated that "neither the Veteran's behavioral health disorder, nor medications to address this condition, CAUSE or promote upper airway obstruction with attendant oxygen desaturation leading to sleep disruption, which is the pathophysiologic mechanism underlying [obstructive sleep apnea." [Emphasis in original] Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). In this case, there are no adequate reasons or bases to adopt one medical opinion over the other. Although the April 2020 VA examiner attempts to refute the opinion of the March 2020 private clinician, his opinion was almost entirely devoted to whether PTSD caused sleep apnea. The examiner did very little to address the issue of aggravation, except in his conclusion (which offered no rationale as to aggravation). Moreover, the examiner did not address the studies cited by the March 2020 private clinician. The Board recognizes that the Veteran also underwent a VA examination in May 2021. The examiner cited all the same evidence as the April 2020 VA examiner and rendered an opinion regarding direct service connection. Ultimately, the examiner opined that the Veteran's sleep apnea was less likely than not incurred in or caused by an in-service event, illness, or injury. The opinion does not address service connection on a secondary basis, and therefore is not probative to the issue of secondary service connection. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for insomnia is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Prem, 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.