Citation Nr: 21010272 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 13-20 204 DATE: February 24, 2021 ORDER Service connection for a sleep disorder, to include sleep apnea, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s sleep disorder onset during service or is otherwise related to service, to include as secondary to his service-connected posttraumatic stress disorder and/or traumatic brain injury. CONCLUSION OF LAW The criteria for service connection for a sleep disorder, to include sleep apnea, have not 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 served on active duty from December 1986 to May 1991. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the appeal in January 2017, September 2018, and August 2020 for further development. There has been substantial compliance with the August 2020 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additional VA treatment records were received after the last adjudication of the case by the RO in a November 2020 supplemental statement of the case. The Board may consider these records without RO consideration as they are cumulative or redundant of evidence of record. See 38 C.F.R. § 20.1304. Service connection for a sleep disorder, to include sleep apnea, is denied. The Veteran seeks service connection for a sleep disorder and contends his sleep disorder is related to in-service drowsiness and inattentiveness or, alternatively, is secondary to his service-connected posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI). 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). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. An April 2017 VA examination reflects a diagnosis of upper airway resistance syndrome. VA treatment records reflect a diagnosis of sleep apnea. Thus, the question for the Board is whether the Veteran’s currently diagnosed sleep disorder onset in service or is otherwise related to service, to include being proximately due to or the result of or aggravated beyond its natural progress by a service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of upper airway resistance syndrome and/or sleep apnea, and evidence shows that the Veteran reports in-service drowsiness and inattentiveness, the preponderance of the evidence weighs against finding that the Veteran’s sleep disorder began during service or is otherwise related to service, to include a service-connected disability. The Veteran’s service treatment records are silent for complaints of, treatment for, and/or diagnosis of a sleep disorder. The Veteran’s enlistment and separation reports of medical examination reflect normal clinical evaluations. The Veteran endorsed a history of ear, nose, throat trouble on his separation report of medical history; however, he denied a history of frequent trouble sleeping. A January 1989 and a May 1990 service treatment record note an unremarkable head, eyes, ears, nose, and throat examination. Post-service, a June 2005 treatment record notes a history of possible sleep apnea and referral for a sleep study. An August 2005 VA treatment record notes snoring and sleep apnea pending a sleep study. A February 2006 VA treatment record notes the Veteran reports loud snoring and that he stops breathing at times during sleep. A May 2006 VA treatment record notes the Veteran’s February 2006 polysomnogram reflects normal sleep efficiency without major sleep disruption. The physician noted ‘suspect upper airways resistance syndrome.’ Subsequent VA and private treatment records reflect sleep apnea and obstructive sleep apnea as active problems. See, e.g., December 2015 VA treatment record. In November 2016, the Veteran’s representative submitted medical literature regarding PTSD and sleep apnea. The Veteran underwent a VA examination in April 2017. The examiner noted a diagnosis of upper airway resistance syndrome. The examiner opined that the Veteran’s claimed sleep disorder is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the Veteran was diagnosed with upper airway resistance disorder in 2006 and placed on a CPAP. The examiner indicated the Veteran’s service treatment records are silent as to any complaints of snoring. He also weighed 177 pounds at separation and 253 pounds at the time of the sleep study. The examiner indicated that he currently weighs 280 pounds and that this excessive weight is the more likely cause of his airway resistance. A May 2017 VA examination notes that the issue of drowsiness or inattentiveness while on active duty could be because of any number of issues, including potentially his sleep apnea. In compliance with prior remand directives, an addendum opinion was obtained in September 2019. The examiner noted that the Veteran has gained significant weight since service and it is the weight that is the more likely cause of his obstruction. He further noted that available literature is only suggestive of a possible correlation between PTSD and obstructive sleep apnea but does not prove causality. Finally, the examiner noted that if either TBI or PTSD did cause any degree of aggravation it would not be to such a degree to outweigh his obesity’s role. In compliance with the Board prior remand directives, an addendum opinion was obtained in October 2020. The examiner opined that it is less likely than not that the Veteran’s sleep disorder, to include sleep apnea, had its onset in or is otherwise related to service, to include his reports of drowsiness and inattentiveness in service. The examiner noted that reports of drowsiness, inattentiveness, and snoring are unspecific symptoms that are not pathognomic of obstructive sleep apnea. The examiner indicated that the Veteran was diagnosed with obstructive sleep apnea in 2006, more than a decade after separation and when he was obese. It is documented in records that his obesity started six to seven years before, making it very unlikely that his obstructive sleep apnea had onset in service. The October 2020 VA examiner further opined that the Veteran’s sleep disorder is less likely than not caused by his service-connected PTSD or TBI. The examiner noted that obstructive sleep apnea is a condition where the patient stops breathing during sleep due to mechanical obstruction of the upper airway. These pauses in breathing usually last ten seconds or longer and breathing usually resumes with a loud gasp, snort, or body jerk. The examiner noted that, despite several studies trying to link sleep apnea and PTSD, there is no proof that one causes the other. Indeed, the examiner indicated that disturbances of sleep in general such as insomnia, dream problems, etc. are frequently associated with PTSD as symptoms of the condition, which is not the same as sleep apnea (a separate medical condition.) Therefore, it is less likely than not that the Veteran’s sleep apnea is secondary to his PTSD or any other mental health condition with which he may be diagnosed. The examiner also indicated that TBI has not been associated causally with sleep apnea. Finally, the examiner indicated that there is no evidence of aggravation of obstructive sleep apnea as his medical treatment records reflect his sleep apnea is well-controlled with CPAP. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding entitlement to service connection for sleep apnea is warranted. The Veteran’s service treatment records are silent as to any diagnosis or symptoms of a sleep disorder. His post-service treatment records reflect diagnosis of a sleep disorder in 2006, over a decade after separation from service. While the Veteran is competent to report having experienced symptoms of drowsiness, inattentiveness, and snoring since service, he is not competent to provide a diagnosis in this case, determine that these symptoms were manifestations of his currently diagnosed sleep disorder, or provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence of record. Taken together, the several VA opinions of record establish that the Veteran’s sleep disorder is not at least as likely as not related to an in-service injury, event, or disease, including his reported in-service symptoms. The combined opinions are probative because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has also considered the Veteran’s contention that his sleep apnea is secondary to his service-connected PTSD and/or TBI. While the Veteran is competent to report evidence within the realm of his personal knowledge, which includes the onset and continuity of his symptoms, the Board reiterates that he is not competent under the facts of this case to provide a nexus opinion. The question of etiology in this case does not lie within the range of common experience or common knowledge but, instead, requires special experience or special knowledge that the Veteran has not been shown to possess. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, to the extent such lay reports were offered as a nexus opinion, they have very little probative value. The weight of the competent and probative medical evidence demonstrate that his service-connected condition does not cause or aggravate his sleep disorder. In reaching this conclusion, the Board has considered the articles submitted by the Veteran addressing sleep apnea and PTSD. However, the treatise evidence must “not simply provide speculative generic statements not relevant to the [claimant]’s claim.” Wallin v. West, 11 Vet. App. 509, 514 (1998). In this case, the articles only provide general information as to sleep apnea and the emerging body of research that suggests that a very high rate of undetected comorbidity may exist between sleep-disordered breathing, PTSD-related nightmares, and PTSD. The articles are not accompanied by any corresponding clinical evidence specific to the Veteran. The articles fail to establish any certainty with regard to the Veteran’s case nor does it reflect plausible causality based upon objective facts. As such, the Board finds this information to be of little to no probative weight in this case. Id. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for a sleep disorder, to include sleep apnea, is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.Aoughsten, 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.