Citation Nr: 21011548 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 12-17 620A DATE: March 2, 2021 ORDER Service connection for left wrist disability, to include as due to environmental exposure in Southwest Asia, is denied. Service connection for a sleep disorder (OSA), to include as due to environmental exposure in Southwest Asia and/or as secondary to service-connected scoliosis and claimed lung condition, is denied. FINDINGS OF FACT 1. The weight of the evidence is against finding that the Veteran’s left wrist disability is due to his in-service basketball injury, and is not shown to have been due to inservice environmental exposure in Southwest Asia. 2. A sleep disorder was not shown in service, is not shown to have been due to inservice environmental exposure in Southwest Asia, is not shown to have been incurred in or aggravated during service and is not shown to be due to or aggravated by the Veteran’s service-connected scoliosis disability or claimed lung disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left wrist disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 2. The criteria for service connection for sleep disorder (OSA) have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1978 to July 1989 and from December 1990 to May 1991, to include service in Southwest Asia from February 1990 to May 1991. This appeal is before the Board of Veterans’ Appeals (Board) from a June 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was scheduled for a date in June 2017. However, prior to the date of the hearing, the Veteran cancelled the hearing and indicated that he was no longer seeking a Board hearing. The Board finds the Veteran’s hearing request withdrawn. See Veteran’s May 2017 correspondence. These claims were previously before the Board in August 2017, December 2019, and most recently September 2020, at which time the claims were remanded for further development, to include obtaining medical nexus opinions to determine if the Veteran’s left wrist and OSA disabilities are etiologically related to his active service. Specifically, the September 2020 Board remand ordered medical opinions to determine whether the Veteran’s current left wrist “strain/pain” diagnosis includes the 1979 in-service left wrist “sprain” and to determine whether the Veteran’s OSA was aggravated (made worse) by his service-connected scoliosis. In addition, prior Board remand directives sought clarification and VA examinations/medical opinions, to include whether the Veteran has a current sleep disability attributable to active service, to include as due to environmental exposure in Southwest Asia and/or service connected asthma. Furthermore, prior Board remands sought clarification and VA examinations/opinions regarding the Veteran’s claimed left wrist disability, to include as due to environmental exposure in Southwest Asia, consideration of additional service treatment notes, Veteran’s in-service contentions and post-service nerve conduction study results. Finally, prior Board remands directed that the Veteran be afforded a Gulf War examination to determine the nature and etiology of any of his undiagnosed symptoms or disorders, including but not limited to his claimed left wrist and sleep disorders. The Board finds that there has been substantial compliance with the Boards prior remand orders; Therefore, the claims have now returned to the Board for further appellate action and discussed in detail below. Service Connection 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). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). 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. Furthermore, service connection may also be established for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016, and cannot be attributed to any known clinical diagnosis by history, physical examinations, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). 1. Service connection for a left wrist condition, to include as due to environmental exposure is denied. The Veteran is seeking service connection for a left wrist condition, initially claimed as residuals of a broken left wrist in 1979 when he fell during physical training. While the Veteran maintains that his left wrist was fractured, the service treatment records (STRs) tell a different story. His STRs revealed no treatment or diagnosis regarding a broken left wrist. An x-ray of the Veteran’s left wrist, showing no fracture or dislocation, was noted in the STRs. A February 1979 STR revealed that the Veteran complained of falling on his outstretched left wrist while playing basketball. He was subsequently diagnosed with a left wrist sprain. There was, however, an August 1979 STR treatment note documenting an oblique fracture of the fourth metacarpal bone of the left hand, which occurred while playing football. A subsequent report of healing is of record in a September 1979 STR. Of note, the Veteran has not filed a service connection claim for his left-hand condition. While a difficult to read entry in the Veteran’s STRs between November 1980 and January 1981 suggest a complaint related to the left wrist, his separation examination in May 1989 revealed no outstanding problems with either wrist. In addition, an examination in April 1991 revealed no clinical abnormalities regarding his upper left extremity and there was no mention of a left wrist injury. Specifically, an April 1991 STR shows that an examination of the Veteran was completed within the previous year and based on this examination the Veteran was physically qualified for separation from extended active duty. In addition, no defects were noted which would disqualify the Veteran from the performance of duties in the selected Marine Corps Reserve. The Board notes that the Veteran signed and dated the examination findings in agreement. No comments regarding a left wrist disability was included by the examiner or added by the Veteran. In addition, a June 1991 oversees service treatment screening STR indicated that no chronic illness was reported. An April 2011 post service private nerve conduction study showed bilateral, moderately severe medial neuropathies at the wrist (carpal tunnel syndrome (CTS)). In light of the 2011 carpal tunnel syndrome diagnosis and the Veteran’s in-service left wrist injury, the Board remanded the Veteran’s left wrist claim in August 2017 to afford him a VA wrist examination, to determine whether this current left wrist disorder is related to service, as he had not yet been afforded such an examination. Pursuant to the Board’s August 2017 remand, the Veteran underwent a VA wrist examination in December 2017. The examiner found that the Veteran did not have a current diagnosis associated with a left wrist condition. The Board notes that the examination reported as history a 1979 left wrist fracture instead of left wrist sprain. It is not clear if the Veteran reported this as history or the examiner in error, as the STRs clearly show left wrist sprain. In any event, upon examination, normal left wrist examination and normal x-rays were reported by the examiner. It was noted by the examiner that the x-rays show degenerative joint disorder (DJD) of the first carpometacarpal joint at the base of the thumb bilaterally. The examiner reported that DJD of this joint is common and is not related to a wrist injury or condition. Ultimately, the VA examiner found that the Veteran’s currently claimed left wrist condition is less likely than not related to service. Rationale provided by the examiner: 1. The Veteran gave a history of injury to the left wrist for which he was treated. 2. After he recovered from that injury, there is no evidence that he had continued left wrist pain or received treatment. He has not received treatment to this day. 3. X-rays show no evidence of a fracture of the left wrist. 4. Currently he has no symptoms or signs suggestive of CTS. 5. X-rays of the hands show DJD at the base of both thumbs which is not related to a left wrist condition. However, in December 2019 the Board noted that an entry in the Veteran’s STRs between November 1980 and January 1981 reflects a complaint related to the left wrist and was not considered by the December 2017 examiner prior to providing the negative direct service connection opinion. Thus, in December 2019, the Board again remanded the Veteran’s left wrist claim for a medical opinion. At a January 2020 wrist examination, the examiner diagnosed the Veteran with a left wrist “strain”. The Veteran reported that the condition started in 1979 as a result of strenuous physical training exercises and symptoms at the time of onset included pain and stiffness. The January 2020 examiner opined that after reviewing the Veteran’s medical records and performing physical examination, it was less likely as not that the Veteran’s current left wrist “strain” was related to service, explaining that the complaint of a left wrist “sprain” documented on active duty in 1979 was more likely an acute event without long term sequala, since there was no sign of continuation of symptomatology during and/or after separation from active service. Thus, it was less likely as not that the Veteran’s current left wrist “strain” was service connected. The examiner noted that there were no records showing progressive complaints between 1979 and the report dated April 2011 nerve conduction study results that were consistent with bilateral, moderately severe medial neuropathies in the wrist. The Veteran’s claim was returned to the Board and again remanded to the RO for additional development in a September 2020 Board remand. The September 2020 Board remand noted that the January 2020 VA examination also reported functional impairment of the Veteran’s (wrist) joint, resulting in difficulty with prolonged typing, writing, difficulty lifting heavy loads, and limited range of motion. As such, the Board in the September 2020 remand found that it is clear that the Veteran experiences some functional impairment due to his claimed wrist condition and that a new medical opinion is required to address whether the Veteran’s left wrist pain constitutes a current disorder under Saunders v. Wilkie, 886 F.3d 1356, 1364(Fed. Cir. 2018), and whether it is related to service. Of note, regarding the “current disability” element of service connection, “pain need not be diagnosed as connected to a current underlying condition to function as an impairment.” Saunders v. Wilkie, 886 F.3d 1356, 1364(Fed. Cir. 2018). Rather, “[t]o establish the presence of a disability, a Veteran will need to show that [their] pain reaches the level of a functional impairment of earning capacity.” Id. at 1367. This definition of “disability” does not “require that pain must affect some aspect of the normal working movements of the body” or that “pain must be tied to physical evidence of a lack of functionality and/or physical evidence of a current disease or injury.” Id. at 1367. Pursuant to the September 2020 Board remand directive, a November 2020, medical opinion for direct service connection was provided. The medical professional opined that the Veteran’s claimed left wrist condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. He confirmed that the Veteran had an acute self-limited left wrist sprain and a separate fourth left metacarpal fracture in 1979. The examiner found the conditions unrelated and both appeared to have been acute and self-limited, with no residuals at the separation examination. The examiner reasoned that this is further supported by the fact the Veteran served again from 1990 to 1991. While, there is no entry examination noted for this timeframe of active-duty service, the VA examiner reasoned that the assumption would be the Veteran was asymptomatic and accepted as whole, with no active wrist condition. Any condition would’ve required evaluation for fitness to serve. The examiner noted that the Veteran served an additional ten years after the sprain. The examiner addressed the discrepancy in histories on the two-prior wrist DBQ’s. The Veteran reported the fracture as a wrist fracture, which it clearly was not (STRs only reflect a left-hand fracture and left wrist sprain). The November 2020 medical professional confirmed that the separation examination was negative for chronic wrist condition. The rationale included that it is unlikely the Veteran could have served ten years with a chronic wrist condition without seeking care. Therefore, she ultimately concluded that it is less likely than not that the Veteran’s current wrist pain/condition, to include degenerative joint disease (DJD), per x-ray in 2017, is due to or incurred in the acute self-limited sprain in 1979. She noted that there is no evidence of ongoing wrist conditions until in or around 2017, which is many years after the Veteran separated from service in 1991. As such, the Board finds that even if the Veteran’s left wrist “strain” constitutes a current disorder under Saunders v. Wilkie, 886 F.3d 1356, 1364(Fed. Cir. 2018), the November 2020 medical professional’s probative opinion clarified in detail that the Veteran’s current left wrist “strain/pain” condition began many years after service is not related to the Veteran’s in-service left wrist “sprain”. The Board acknowledges the Veteran’s assertion that he believes he sustained a broken left wrist in 1979 when he fell during physical training with continued pain. However, the competent and credible evidence of record does not support his assertions. The STRs show an inservice left wrist sprain occurred during a basketball game and a complaint of left wrist pain many years after separation from service. Furthermore, the Veteran has received several VA examinations regarding his left wrist condition. However, every opinion that were provided was negative. The November 2020 examiner specifically took into account the Veteran’s STRs, and his statement as to how he injured his left wrist, and his post-service treatment record/complaints regarding his left wrist. The Board also recognizes the Veteran’s assertion that he sustained a wrist fracture and not a wrist sprain in service; however, as previously stated, the medical evidence of record suggests that the left wrist was not actually fractured, but rather was sprained. In this case, there is no contemporaneous medical evidence to support an assertion of continuity of symptomatology, and the Veteran specifically denied problems on his medical history survey completed in conjunction with his separation physical. In addition, in 1991, the Veteran signed an examination assessment in agreement that no defects were noted which would disqualify him from the performance of duties in the selected Marine Corps Reserve. As such, it appears he first sought treatment for his left wrist at least 20 years after his separation from the military. Further, the VA examiners acknowledged the Veteran’s reports of an in-service injury and post-service symptoms/treatment record, yet negative nexus opinions were still provided. Regarding undiagnosed symptoms or disorders, to include his claimed left wrist condition, as the record reflects that the Veteran served active service in the Southwest Asia theater of operations during the Persian Gulf War, and service connection may also be established for a Persian Gulf Veteran, a Gulf War examination was directed by the Board’s August 2017 remand to determine the nature and etiology of any of his undiagnosed symptoms or disorders, including but not limited to his claimed left wrist condition. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). Pursuant to the Board’s August 2017 remand, the Veteran was afforded a Gulf War DBQ in December 2017, to include left wrist. The physician determined that there are no diagnosed illnesses for which no etiology was established, and the Veteran did not report any additional signs and/or symptoms not addressed through completion of DBQs. No functional impact of additional signs and/or symptoms that may represent an “undiagnosed illness” or “diagnosed medically unexplained chronic multi symptom illnesses” was noted regarding the Veteran’s left wrist. Furthermore, the December 2017 wrist examiner explained that while wrist pain is a disease with a clear and specific etiology and diagnosis, it is less likely than not that this condition is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner stated that this conclusion is reached because there is no evidence in the literature that such a connection is likely. The Board finds the December 2017 opinion probative because it is well-reasoned rationale that was grounded in the medical literature and the specific facts of the Veteran’s situation. As such, the Board finds that this alternate theory for service connection is not warranted. To the extent that he believes that his left wrist condition is a result of his in-service basketball injury, to include environmental exposures in Southwest Asia, such a medical opinion requires medical expertise, and that determination cannot simply be made by lay observation alone; and the Veteran is not considered competent (meaning medically qualified by training or experience) to provide a medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, several VA examinations were ordered to address the Veteran’s assertions and to provide an etiology opinion. Unfortunately, after taking into account the Veteran’s STRs, lay statements of record and examination, each VA examiner provided a negative nexus opinion. The Board notes that there is no competent medical opinion of record that would undermine the VA examiner’s medical opinions. The Board concludes that the evidence does not support the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. 2. Service connection for OSA, to include as due to environmental exposure and secondary to service-connected scoliosis and/or asthma, is denied. The Veteran is seeking service connection for an obstructive sleep apnea (OSA) as a result of his military service, to include as due to environmental exposures and secondary to his service-connected scoliosis disability and claimed lung condition. The Veteran contended in his January 2005 application that he experienced difficulty sleeping at night due to breathing problems, which began after his return home from Operation Desert Storm, where he was exposed to smoke from oil wells being blown up. A March 1991 administrative note stated that the Veteran participated in the breeching operation of Operation Desert Storm in Kuwait and was subsequently in or adjacent to the Burgan Oil Field in February 1991, that the smoke from the oil fires was often covering positions occupied by the Veteran, that the smoke was so dense that visibility was cut to less than 30 feet during clear mid-day hours, that the ground turned grey-black in many areas traversed or occupied by the Veteran, and that vehicles and clothing were covered by oil droplets. However, STRs were silent for complaints or a diagnosis relating to a sleep disorder. The Veteran’s separation examination in May 1989 also reported no outstanding problems relating to sleep. The Veteran was afforded a VA examination in July 2008. There, he reported symptoms such as sweatiness and dreams of his service in Desert Storm. He reported that he was waking, wandering around the house, and getting a drink of water before returning to bed. This occurred roughly two times per month. At that time, the Veteran was not diagnosed with obstructive sleep apnea (OSA). The Veteran and his wife submitted lay statements stating that the Veteran continued to have sleep problems due to his shortness of breath and wheezing. The Board notes that the Veteran is currently service connected for asthma. An April 2014 VA treatment record reflects that studies indicated that the Veteran did not get adequate sleep; he was referred to mental health to address his nightmares and sleep issues. Of note, the Veteran is currently service connected for posttraumatic stress disorder (PTSD) and adjustment disorder with depression and insomnia. Accordingly, in August 2017, the Board remanded the Veteran’s claim for a VA examination to determine whether the Veteran has any other sleep disorder other than the PTSD-related insomnia, to include commenting on the claimed relationship between the Veteran’s sleep problems and his asthma. In addition, the Veteran’s claim was remanded for a Gulf War examination to determine the nature and etiology of any of his undiagnosed symptoms or disorders, including but not limited to his claimed sleep disturbances. In December 2017, the Veteran was afforded a VA examination. A December 2017 sleep study was noted with a diagnosis of obstructive sleep apnea. The examiner noted that the Veteran had only recently been diagnosed with OSA, and this diagnosis was confirmed by another positive sleep study dated in January 2018. The examiner reviewed the Veteran’s entire claims folder, examined the Veteran and reported that his claimed disability pattern, obstructive sleep apnea, represented a disease with a clear and specific etiology and diagnosis. The VA examiner opined that the Veteran’s OSA was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Furthermore, the examiner reported that there is presently no medical literature to support a correlation between obstructive sleep apnea and Gulf War exposures. A December 2017 medical opinion DBQ is also of record. The VA medical professional confirmed diagnosis of obstructive sleep apnea. She also opined that it is less likely than not (50 percent or less probability) that his claimed disorder, obstructive sleep apnea, either onset during Veteran’s active service or was otherwise caused by his active service. She explained that review of the service treatment records did not document evaluation or treatment for complaints of snoring or daytime somnolence. While the December 2017 examiner provided negative OSA nexus medical opinions, the Board noted in a December 2019 Board remand order that the prior August 2017 remand, had specifically requested the examiner to comment on the claimed relationship between the Veteran’s sleep problems and his claimed “lung disorder.” As no such discussion has occurred, in December 2019 the Board determined that a remand was warranted to obtain a new examination and etiology opinion that addressed the Veteran’s sleep problems, to include his claimed lung disorder. Pursuant to the Board’s December 2019 remand, the Veteran was afforded a January 2020, sleep apnea DBQ and examination. The examining physician noted that the Veteran was first diagnosed with obstructive sleep apnea in December 2015. A January 2020 sleep study confirmed his OSA diagnosis. Upon examination, the Veteran did not require continuous medication, nor did he have symptoms attributable to sleep apnea. The January 2020 medical opinion addressed undiagnosed illness in relationship with service connection consideration for sleep condition. The examiner concluded that after reviewing medical records and performing physical examination, it is less likely than not that the Veteran has an undiagnosed illness or medically unexplained chronic multisystem illness that is defined by a cluster of signs or symptoms is service connected as there are no medical records showing diagnosis, treatment for the an undiagnosed illness or medically unexplained chronic multisystem illness that is defined by a cluster of signs or symptoms condition while the Veteran was still in service. Regarding environmental exposure in Southwest Asia and claimed lung condition, in a separate opinion, the January 2020 examining physician found that the Veteran’s obstructive sleep apnea was less likely as not related to his service, to include environmental exposure in Southwest Asia, as there were no medical records showing diagnosis, treatment for or relating to obstructive sleep apnea during service. The physician acknowledged the Veteran’s October 2007 contentions that he had sleeping difficulties as a result of his time in Operation Desert Storm, specifically due to oil and smoke inhalation, and the Veteran’s wife’s March 2009 and May 2010 statements indicating that the Veteran experienced shortness of breath and wheezing upon his return from Operation Desert Storm, which prevented him from getting a good night sleep. However, the physician found no direct correlation or causal relationship between inhalation of smoke, oil, and lung disorder causing or inducing obstructive sleep apnea, as there was no medical physiology to explain such a relationship. There were a number of studies that record a high prevalence of OSA in patients with lung issues, such as asthma. However, these studies only showed prevalence, which did not equate to causation. The studies did not provide a conclusion that asthma or that smoke/inhalation caused OSA. As noted above, the Veteran is currently service connected for asthma. The Veteran’s claim was returned to the Board. In September 2020 the Board noted that based on the evidence detailed above, which includes the Veteran OSA diagnosis/symptoms at the earliest 2015 (many years after separation from service) and probative negative nexus opinions supported by the evidence of record, a direct service connection may not be established between the Veteran’s military service and his current obstructive sleep apnea to include as due to inservice exposure to environmental exposure in Southwest Asia. Accordingly, the Board finds that the weight of the evidence is comfortably against the claim on a direct basis, and that the claim must be denied. However, in September 2020 the Board found that the December 2017 Gulf War examination may suggest a link between his service-connected scoliosis and his obstructive sleep apnea meeting a secondary service-connection criterion. Specifically, the report indicated that the Veteran’s scoliosis compromises lung function by decreasing its expansion. This leads to oxygen desaturation, which may contribute to obstructive sleep apnea. Thus, the September 2020 Board remanded the Veteran’s claim to obtain a medical opinion regarding a possible nexus between the Veteran’s service-connected scoliosis and his current OSA. The BVA remand directed a medical opinion to clarify if the Veteran’s current OSA is related to or aggravated by his service-connected scoliosis. Pursuant to the September 2020 Board remand, the November 2020, medical professional opined that the Veteran’s OSA is less likely than not (less than 50 percent probability) proximately due to or the result of Veteran’s service-connected scoliosis condition. Specifically, he explained that by definition, OSA is due to obstruction of the upper airways, associated with apneic episodes, and there is no anatomic or physiologic mechanism by which the Veteran scoliosis could cause or aggravate the Veteran’s OSA. The medical professional noted that this is established medical knowledge and practice. See the treatise cited as OSA - https://www.aafp.org/afp/1999/1115/p2279.html (relationship to scoliosis). The medical profession explained that the study cited above did note a higher incidence of apneic episodes in individuals with scoliosis verses control subjects. This did not establish cause and effect. The medical professional explained that literature review, including Up to Date (well-respected source) did not yield any studies concluding cause and effect. Scoliosis can have an impact on restrictive lung disease, but this is an unrelated condition to OSA. The exception to scoliosis causing OSA is in the case of neuromuscular diseases causing the scoliosis. The VA medical professional reasoned that the Veteran’s scoliosis disability is idiopathic, and not due to neuromuscular disease, such as polio. Therefore, it is less likely than not that the Veteran’s OSA is due to scoliosis. moreover, the medical professional opined that is less likely than not that the Veteran’s OSA has been aggravated/made worse due to any cause. Here, the Veteran’s OSA was not diagnosed until at least 2015, more than 20 years after separation from service. The Board finds that the January 2020 and November 2020 VA opinions to be highly probative evidence against the possibility that the Veteran’s OSA is related to his environmental exposure, undiagnosed illness and/or service-connected scoliosis/asthma, given the reviews of the claims file, consideration of the Veteran’s specific contentions, medical/service history, notably relevant medical literature, and discussion of the rationale of the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA opinions provided substantial reasoning and explanation as to why the Veteran’s sleep disorder was not due to his active service, was not due to environmental exposure, was not caused by the Veterans service-connected scoliosis disability or related to a claimed lung condition. With regard to the possibility of aggravation of sleep apnea by scoliosis, the November 2020 opinion specifically addresses the secondary claim. Here, the opinion concludes that the Veteran’s OSA was not proximately due to/aggravated by/or the result of his service-connected condition (i.e. scoliosis disability). 38 C.F.R. § 3.310. Furthermore, the November 2020 medical professional also opined that it is less likely than not that the Veteran’s OSA has been aggravated/made worse due to any cause, which would include a claimed lung condition or service-connected asthma disability. Accordingly, the Board finds that the weight of the evidence is comfortably against the claim on secondary basis, and that the claim must be denied. Indeed, despite the Veteran’s sincere beliefs otherwise, as a layman, he is simply not competent to attribute his present OSA to in-service environmental exposure, undiagnosed illness or a service-connected disability, as this is the type of assessment that requires specialized medical expertise and training. See 38 C.F.R. § 3.159 (a)(2); and Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection). Rather, OSA is a medically complex condition whose etiology requires specialized medical expertise, as well as diagnostic testing, not simply lay observation and experience. The Veteran simply lacks the medical training or expertise to draw that type of medical conclusion. The Board concludes that the evidence does not support the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Franklin, 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.