Citation Nr: 21074808 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 16-56 565 DATE: December 16, 2021 ORDER Service connection for obstructive sleep apnea (OSA) is granted. FINDING OF FACT Resolving all doubt in his favor, the Veteran has a current diagnosis of OSA which has been related to the Veteran's service-connected post-traumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for OSA have been 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 military service from November 1988 to March 1992, September 2001 to April 2002, February 2003 to April 2004, and from June 2004 to February 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in March 2019, at which time the above issue was remanded for further development. Legal Criteria Service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis The Veteran contends that he has OSA which is related to his active duty military service, or alternatively, secondary to weight gain which he asserts is secondary to his service-connected post-traumatic stress disorder (PTSD). While the Veteran contends that he has experienced OSA symptoms since his military service, the Veteran's service treatment records are negative for any indications of OSA. Post-service treatment records show that the Veteran was diagnosed with OSA as early as 2012. The Veteran submitted an initial claim for service connection for OSA in January 2014. In connection with this claim, he was afforded a VA sleep apnea examination in August 2015. Significantly, the August 2015 VA examiner continued a diagnosis of OSA and found that the Veteran's OSA is more likely than not due to the Veteran's documented obesity since his separation from active service. The examiner also explained that the proximate cause of the Veteran's OSA is a developmentally narrow oropharyngeal airway, with superimposed elevation of BMI, which creates an encroachment of the airway with fatty soft tissue. As such, the examiner expressed an opinion that it is less likely than not the Veteran's OSA was caused by, related to, or aggravated by any incident in service, including- to the extent that it is asserted- any exposure to environmental hazards from the Gulf War. 38 C.F.R. § 3.317(a)(2)(i). Also of record is a March 2021 statement from Dr. C.C., the Veteran's private physician which relates the Veteran's OSA to his service-connected PTSD. The statement unequivocally makes three dispositive findings. First, that the Veteran's weight gain and obesity, well-documented throughout his records, is due to and/or related to his service-connected PTSD. Second, that it is at least as likely as not that the Veteran's OSA is secondary to, related to, and/or aggravated by the weight gain and obesity which has resulted from PTSD. Third, that it is at least as likely as not that, without the weight gain caused by the service-connected PTSD, the Veteran's OSA would not have occurred. Dr. C.C. detailed the Veteran's medical history, demonstrated familiarity with the Veteran's service treatment records and medical treatment thereafter, and based her rationale on medically supported reasoning. Attached to this opinion are dozens of abstracts from numerous peer-reviewed medical studies, which attribute the onset of OSA, specifically in veterans, to the experience and diagnosis of PTSD and resulting weight gain from the symptoms and medications used to mitigate a PTSD disability. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for sleep apnea is warranted. As an initial matter, the Board finds that the Veteran has a current diagnosis of OSA. Furthermore, there is medical evidence that such disability is related to the Veteran's service-connected PTSD. While the Veteran is not service-connected for obesity specifically, the rationale provided in the March 2021 private opinion explains the intricate interwoven nature of the treatment for PTSD, acknowledging a resulting symptom of obesity from use of medication, in conjunction with the pathophysiology of excessive food intake related to mood disturbance, along with sleep disturbance resulting in lethargy, and the cyclical effect of them all. There is no contrary medical opinion of record. Accordingly, the Board resolves all doubt in favor of the Veteran and finds that OSA is related to his service-connected PTSD. Therefore, service connection for OSA is warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310; Gilbert, supra. APRIL MADDOX Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Sutherell, 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.