Citation Nr: 21010810 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 17-56 752 DATE: February 25, 2021 ORDER Entitlement to service connection for obstructive sleep apnea, claimed as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT The Veteran’s obstructive sleep apnea was not caused or aggravated by his service-connected PTSD or otherwise related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for obstructive sleep apnea, claimed as secondary to PTSD, 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 November 1965 to November 1968. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in April 2019 for further development by the RO. The case has been returned to the Board for further appellate action. Entitlement to service connection for obstructive sleep apnea, claimed as secondary to PTSD The Veteran asserts that his sleep apnea is due to his service-connected PTSD. 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 also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The record in this case is clear as to whether the Veteran has obstructive sleep apnea, which was diagnosed in 2014. See February 2015 VA examination. Thus, the first element of service connection, the existence of a current disability, is satisfied. The record is also clear that the Veteran is service connected for PTSD. See July 2019 rating decision code sheet. The Veteran submitted an August 2014 private sleep study report confirming findings of severe obstructive sleep apnea. In September 2014, the Veteran submitted an article by Dr. R.R. regarding the connection between PTSD and sleep apnea. The Veteran also submitted a private opinion from Dr. J.R., dated September 2014, stating that he believes the Veteran’s waking up from sleep is related to his PTSD. No rationale or explanation was provided for this conclusion. The Board finds that this opinion lacks probative value as the opinion fails to meet the required evidentiary standard as “related to” is too speculative upon which to base a grant of service connection. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are too speculative, general, or inconclusive in nature cannot support a claim). It also fails to provide a supporting rationale for its conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In September 2014, the Veteran’s wife submitted a letter stating that, for many years, she has had to wake him up or alert him with a touch because he holds his breathe, stops breathing, or snores loudly. He experiences significant tiredness, which has gotten worse over the past few years. See September 2014 lay statement. The Veteran underwent a VA examination in February 2015. The examiner opined that it is less likely than not that the Veteran’s sleep apnea is proximately due to or the result of PTSD. The examiner explained that the primary causes of sleep apnea are enlarged soft tissue, pharyngeal narrowing, or loss of musculature, all of which are structural conditions not impacted by PTSD. The examiner further stated that the Veteran left service in 1968 and there is no medical evidence of sleep apnea issues until 2014, and presumably the PTSD was present during this interval. The examiner also reviewed Dr. J.R’s opinion and noted that there is no medical documentation to support this opinion. It did not contain a statement as to the type of causal relationship between sleep apnea and PTSD. The examiner also reviewed the article submitted by the Veteran. He noted that the article is not a study, but rather the opinion of the author, and is not substantiated by medical evidence. In October 2017, the Veteran contended that the conditions are related because he wakes up yelling, unable to breathe, and gasping for air. His wife pokes him multiple times during the night because he stops breathing. See October 2017 Form 9. The Board remanded the claim in April 2019 to obtain an addendum opinion regarding secondary aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013). In a January 2020 VA medical opinion, the examiner opined that the Veteran’s sleep apnea is less likely as not proximately due to, the result of, or aggravated by his service-connected PTSD. The medical literature was reviewed and there is nothing to establish that PTSD causes or aggravates sleep apnea. The risk factors for sleep apnea, based on the medical literature, are age, gender, craniofacial and upper airway abnormalities, among others. The examiner cited multiple supporting medical articles. The Board acknowledges the lay statements of record and the assertion that the Veteran’s sleep apnea is related to his service-connected PTSD. However, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex. He does not have the requisite specialized knowledge, training, or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Thus, although the Board has carefully considered these lay contentions, the Board ultimately affords the objective medical evidence of record, which weighs against finding such a connection, with greater probative weight than the lay opinion. Consequently, the Board affords more probative weight to the competent medical evidence of the February 2015 and January 2020 VA examination report and addendum opinion. Here, the Board finds that the VA medical opinions are based on an accurate medical and lay history as well as medical documentation provided in the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning). Additionally, the Board notes that neither the Veteran nor his representative have presented or identified any adequate contrary medical opinion or treatment that supports his claim. The Board notes that the Veteran has contended that his sleep apnea is secondary to his service-connected PTSD. See September 2014 statement in support of claim. The Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection. The AOJ addressed direct service connection. Neither the medical evidence or the Veteran’s contentions raise specific evidence as to direct service connection. On this record, direct service connection is not warranted. 38 C.F.R. §§ 3.102, 3.303 As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine cannot be applied. 38 U.S.C. § 5107(b); Gilbert v. Derwinksi, 1 Vet. App. 49, 53-56 (1990). Thus, service connection for sleep apnea is not warranted. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Minaya, 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.