Citation Nr: 21076042 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 18-43 758 DATE: December 22, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to service connection for a left hip disability is granted. FINDINGS OF FACT 1. The evidence of record supports finding that the Veteran's service-connected posttraumatic stress disorder (PTSD) caused or aggravated his obesity, which, in turn, caused or aggravated his OSA. 2. The evidence of record supports finding that the Veteran's service-connected PTSD caused or aggravated his obesity, which, in turn, caused or aggravated his left hip disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for OSA are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for a left hip disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1987 to November 1987 and February 2003 to April 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2017 and April 2018 Rating Decisions by a Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was conducted via the virtual hearing process. A transcript of this hearing is contained within the electronic claims file. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1380 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). The Veteran alleges that his service-connected PTSD has caused his OSA and that his left hip disability is attributable to either his service-connected right hip or low back disability. Aug. 18, 2021, Hr'g Tr. (Tr.) at 2, 10. For disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war or peacetime, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. §§ 1110, 1131. To establish secondary service connection, a veteran must provide evidence of (1) a current, non-service-connected disability, (2) a current service-connected disability, and (3) evidence that the non-service-connected disability is either (i) proximately due to or the result of a service-connected disability or (ii) aggravated (increased in severity) beyond natural progression by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc); 38 C.F.R. § 3.310. Office of the General Counsel Opinion 1-2017 (the "OGC Opinion") holds that obesity may qualify as an "intermediate step" between a service-connected disability and a current disability. VAOPGCPREC 1-2017. Thus, service connection for a current disability may be established under 38 C.F.R.§ 3.310(a) if it can be shown that (1) the service-connected disability in question "caused the veteran to become obese," (2) the obesity "was a substantial factor in causing" the claimed disability, and (3) the claimed disability would not have occurred but for the obesity. Id. The United States Court of Appeals for Veterans Claims (CAVC) expanded OGC's opinion by holding that obesity can serve as an intermediate step both where it is caused or aggravated by a service-connected condition. Walsh v. Wilkie, 32 Vet. App. 300, 306 (2020). 1. Entitlement to service connection for OSA is granted. February 2015 private treatment records confirm that the Veteran underwent a sleep study and was diagnosed with OSA. Over the course of this appeal, there have been several medical opinions rendered. There is a May 2016 opinion from the Veteran's private treating physician for his OSA, indicating that his PTSD is an "aggravating factor to his [OSA]." August 2016 and January 2017 VA opinions, however, concluded the opposite, finding that the overall medical literature, while indicating a potential relation between to the two, does not confirm that PTSD causes or aggravates OSA. After his hearing, the Veteran submitted a medical opinion by Dr. R.L. Importantly, he opines that the Veteran's PTSD has exacerbated his obesity, which, in turn, has caused his OSA. An obesity argument never was advanced at any point prior to the Veteran's submission of Dr. R.L.'s opinion, but the Board finds that it deserves significant probative value on appeal. Dr. R.L. provides an in-depth discussion to the debilitating affects that psychiatric conditions can have on one's health, including weight gain and obesity. He devotes two full pages, discussing medical literature that support that conclusion. He then cohesively ties together, again supported by multiple medical sources, the missing link for the Board: that obesity is both a "high risk factor for the development of [OSA]" and continues to be the "main factor that contributes to [OSA]." This well-articulated, thorough opinion contains the hallmarks of one worthy of full probative value on appeal. See McCray v. Wilkie, 31 Vet. App. 243, 257 (2019). Thus, the Board is satisfied that the elements for an intermediate-obesity theory of service connection has been established. Dr. R.L.'s opinion shows that the Veteran's PTSD caused obesity, obesity was a substantial factor in causing OSA, and OSA would not have occurred but for the Veteran's obesity. See Walsh, 32 Vet. App. at 306; 38 C.F.R. § 3.310. 2. Entitlement to service connection for a left hip disability is granted. As noted above, the Veteran advances that his left hip disability is secondary to either his service-connected back or right hip. He never has articulated an obesity-type argument, but the Board finds that it is applicable for this issue as well. An April 2018 VA examination confirms that the Veteran has bilateral osteoarthritis of the hips and underwent replacement in each. That examiner, in opining that the Veteran's left hip disability is unrelated to the back condition, also noted that "the Veteran has high BMI [43.27] . . . would cause abnormal stress on all weight bearing joints including both hips causing [degenerative joint disease]." The Board already has found as probative Dr. R.L.'s opinion that the Veteran's service-connected PTSD caused his obesity. For this issue, the VA examiner's opinion picks up where Dr. R.L. leaves off. The former indicates that the Veteran's obesity would have caused abnormal stress on his hips, which then caused his arthritic condition. The Board likewise finds that this opinion clearly satisfies the necessary requirements for obesity as an intermediate step between the Veteran's service-connected PTSD and his left hip disability. Thus, service connection for a left hip disability is appropriate. See Walsh, 32 Vet. App. at 306; 38 C.F.R. § 3.310. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Trevor T. Bernard, 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.