Citation Nr: 21076124 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 17-09 570 DATE: December 22, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to service-connected posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT Resolving reasonable doubt in favor of the Veteran, his OSA is proximately due to his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for OSA as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1970 to February 1972. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Generally, to establish service connection 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." Davidson v. Shinseki, 581 F.3d 1313, 131516 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (worsened in severity beyond its natural progress) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 44849 (1995). Entitlement to service connection for OSA, to include as secondary to service-connected PTSD. In May 2014 the Veteran filed an application for service connection for OSA claiming that it was secondary to his service-connected PTSD. In support of his claim, the Veteran provided two articles titled "Impact of Untreated Obstructive Sleep Apnea on Glucose Control in Type 2 Diabetes" and "CPAP therapy reduced nightmares in patients with PTSD, sleep apnea". The Board notes that the Veteran is also service connected for type II diabetes mellitus. A review of the Veteran's treatment records show he is currently diagnosed with OSA. In August 2016, the RO obtained a medical opinion regarding the Veteran's OSA and its relationship to his service-connected PTSD. The VA examiner opined that the Veteran's OSA was less likely than not proximately due to or aggravated by his PTSD. As rationale for his opinion, the VA examiner noted that the Veteran had multiple risk factors for OSA, such as obesity, age, male sex, smoking, and a somewhat narrowed airway. The examiner further explained that "the medical literature does not mention PTSD as a cause or risk factor for sleep apnea. This makes sense considering that PTSD has no effect on the muscles of the airway resulting in sleep apnea. While there have been several articles referencing the presence of sleep apnea in individuals with PTSD, there is still no medical evidence showing that PTSD actually causes sleep apnea." The Veteran appealed this issue up to the Board. In support of his claim, the Veteran, through his representative, provided a private medical opinion from a doctor who specializes in pulmonary medicine in May 2020. In his report, Dr. L.M.G. explains that he reviewed the Veteran's entire claims file as well as his VA and social security treatment records. Dr. L.M.G. provided background information, occupational history, and a medical summary for the Veteran in his report before opining that it is his professional opinion that the Veteran's OSA "is, more likely than not, due to and related to his service-connected PTSD." As rationale for this opinion Dr. L.M.G. discusses the "extensive study in medical literature regarding the correlation between OSA and PTSD." Dr. L.M.G. also discusses the August 2016 VA opinion noting that he respectfully disagrees with the conclusions reached because while the VA examiner was correct to point out the Veteran's risk factors, he incorrectly ignored the extensive medical literature that confirms the relationship between PTSD and OSA. Specifically, Dr. L.M.G. wrote "In the medical literature, not only is there a high correlation of these with comorbid conditions (ie. PTSD and OSA), but, the literature also confirms that sleep fragmentation, such as seen in PTSD, increases the propensity for upper airway collapse in patients with sleep apnea." The Board finds this opinion to be well reasoned and supported by the record. The Court of Appeals for Veterans Claims reiterated in Wise that "[b]y requiring only an 'approximate balance of positive and negative evidence' to prove any issue material to a claim for Veterans benefits, 38 U.S.C. § 5107(b), the nation, 'in recognition of our debt to our Veterans,' has 'taken upon itself the risk of error' in awarding such benefits." Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (citing Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990)). As the evidence in this case is in at least equipoise, entitlement to service connection for OSA, as secondary to service-connected PTSD, is granted. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Ruiz, 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.