Citation Nr: 21010711 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 16-19 441A DATE: February 25, 2021 ORDER Entitlement to service connection for sleep apnea, to include as due to the Veteran's service-connected posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran’s sleep apnea is not secondary to service-connected PTSD, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for sleep apnea due to service or service-connected disease or injury are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from November 1964 to November 1968, with confirmed service in the Republic of Vietnam. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2014, rating decision of the Phoenix, Arizona, Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his spouse appeared before the undersigned Veterans Law Judge in a videoconference hearing in May 2019 to present testimony on the issue on appeal. This matter was before the Board in October 2019, at which time the Veteran’s claim was remanded for further development. The matter was last before the Board in August 2020, at which time the Board remanded again finding there had not been substantial compliance with the October 2019 remand. There has been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to service connection for sleep apnea, to include as due to the Veteran’s service connected PTSD. Another remand is not required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for sleep apnea, to include as due to the Veteran's service-connected posttraumatic stress disorder (PTSD) The Veteran has asserted that symptoms of his sleep apnea began while on active duty or in the alternative was aggravated or caused by his PTSD. There is evidence that demonstrates association to PTSD and sleep apnea from an August 2016 private opinion letter. This opinion does not demonstrate a causal relationship or nexus between the Veteran’s diagnosed PTSD and his diagnosed sleep apnea as it provides no reasoning, rationale, or evidence to support this assertion and does not relate to the Veteran’s symptoms or conditions specifically. As such, the opinion has no probative value. The Board previously remanded this matter in October 2019, after finding the medical evidence of record inadequate to decide the appeal. The remand directives requested an opinion on a direct and secondary basis. In December 2019, a VA examination with opinion was completed. The examiner opined that the Veteran’s sleep apnea was less likely than not related to an in service injury, event or illness. The examiner opined that the Veteran demonstrates the number one risk factor for sleep apnea, which is obesity, that was not present during service or for several years after service. The examiner states that one would have to look no further for causes of sleep apnea. The examiner’s rationale does not speak to why that is. The examiner’s rationale provides the condition is readily explained by upper airway collapse during sleep. The examiner’s opinion does not address the relationship of the Veteran’s complaints of snoring dating to his service, though the examiner notes the Veteran’s credible history of snoring and lay evidence provided by the Veteran’s three wives describing snoring and apneic episodes. While obesity may be the number one risk factor and an upper airway collapse during sleep may be a physical factor for sleep apnea, the examiner does not explain how these factors have to do with the Veteran’s sleep apnea. The examiner further opines that causation by PTSD has not been shown. The examiner cites to literature that demonstrates there is an association of sleep apnea with PTSD and mood disorders. In referring to the literature, the examiner notes sleep apnea can be detected at a very high percentage in patients with mood disorders who demonstrate any suggestive risk factors including signs or symptoms suggestive of sleep apnea; and that there is a high rate of undetected sleep apnea in patients who are being diagnosed as having mood orders which would implicate PTSD as well. The examiner’s rationale noted an association of sleep apnea with not only PTSD but mood disorders in general. It was stated that causation however by these mental conditions including PTSD has not been shown. The rationale discussed a causal relationship or nexus between the Veteran’s PTSD and sleep apnea; the rationale does not support the opinion of causation by PTSD not being shown. The examiner’s opinion does not account for any aggravation of the Veteran’s sleep apnea by his PTSD. The opinion is therefore incomplete for adjudication purposes, as an aggravation analysis is required for a secondary service connected claim. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (medical opinion that a disorder is not the result of an already service connected disability does not address the issue of aggravation). For this reason the Board remanded the claim for an additional medical opinion addendum in August 2020. In the August 2020 VA medical opinion addendum, the examiner opined that the Veteran’s sleep apnea is at least as likely as not related to the reported symptoms of snoring, insomnia, daytime sleepiness while on active duty. The examiner provided the following rationale: Snoring without sleep apnea is normal and just disordered breathing, the condition the Veteran had in service. Snoring without associated airway compromise, sleep disturbance, or other consequences is essentially normal. The weight of medical literature supports that obstructive sleep apnea is a condition in which tissues in the throat occlude the passage of air during the relaxation of sleep. It is primarily a biomechanical condition whose primary risk factors are age (increasing from young adulthood), gender (male), obesity (the strongest risk factor), family history, and craniofacial abnormalities. Alcohol, and smoking are also well-known risk factors. The examiner also opined that the Veteran’s sleep apnea is not at least as likely as not proximately due to his service connected PTSD or aggravated beyond its natural progression by his service connected PTSD. The examiner provided the following rationale: In addition, there are many conditions with known association with sleep apnea. Association is just that, meaning that the conditions co-exist, not that one causes the other. Specifically, PTSD may be associated but not causing sleep apnea, like any other condition. As is now evident, Veteran’s massive obesity and progressive weight gain, along with the aging process, male gender, and as previously noted Mallampati score, neck circumference, all are the proximate cause(s) and aggravating factors for sleep apnea. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical 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). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the August 2020 opinion was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinions. The examiner has addressed the possibility of the Veteran’s sleep apnea of being related to snoring and caused or aggravated by PTSD. The examiner has medically ruled out the claimed causes based on the individual facts of the Veteran’s claim. The opinion is also shown to have been based on a review of the Veteran’s record and is accompanied by a sufficient explanation as to why the Veteran’s sleep apnea is not caused or aggravated by the Veteran’s PTSD; or related to reports of in-service snoring. The Board thus finds that the August 2020 addendum opinion is probative and outweighs the August 2016 private opinion. As the preponderance of the evidence weighs against the Veteran’s claim for service connection for sleep apnea, to include as due to his service-connected PTSD disability, the benefit of the doubt rule is not for application. See 38 U.S.C. § 5107 (b). Therefore, the Veteran’s claim must be denied. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Lang, Attorney Advisor 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.