Citation Nr: 21022545 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 16-27 398 DATE: April 16, 2021 ORDER Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), diabetes mellitus, and peripheral neuropathy, is denied. FINDING OF FACT The Veteran’s sleep apnea is not secondary to service-connected PTSD, diabetes mellitus, and peripheral neuropathy, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for sleep apnea due to service or service-connected PTSD, diabetes mellitus, and peripheral neuropathy have not been 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 from July 1961 to October 1971. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision that denied service connection for sleep apnea. In July 2020, the Board remanded the issue for further development, which has been completed. This is the only issue on appeal. The Veteran contends that his sleep apnea had onset while in service. Alternatively, he contends that his sleep apnea is due to his PTSD, diabetes mellitus, and peripheral neuropathy. Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) a current disability, (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury, and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To establish service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a)(b) (2016), Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Veteran has been diagnosed with sleep apnea, and therefore satisfies the first element for establishing service connection of a current disability. See September 2020 VA Examination. Service treatment records (STRs) show that the Veteran continuously denied frequent trouble sleeping and on his October 1971 exit examination. Furthermore, the Veteran was not diagnosed with sleep apnea until 1993, decades after active service. See September 2020 VA Examination. The September 2020 VA examiner also opined that the Veteran’s sleep apnea is less likely than not incurred in, caused by, or proximately due to military service (to include psychiatric stressors the Veteran experienced during service), as there is no anatomic or physiologic nexus to connect the conditions. The examiner reviewed the Veteran’s claims file, STRs, and clinical examination, and noted the evidence of record demonstrates the Veteran was diagnosed with obstructive sleep apnea in 1993. Furthermore, there is no evidence of symptoms, complaints, assessment, or treatment for any sleep disorder during service, or at any time prior to 1993. Because the Veteran’s STRs do not show ongoing complaints or treatment of sleep apnea or difficulty sleeping, the claim will be denied on a direct basis. However, the Board will also consider whether the Veteran’s sleep apnea may be secondary to any of his service-connected conditions, such as his PTSD, diabetes mellitus, and peripheral neuropathy. The Board concludes that, while the Veteran has a current of sleep apnea, the preponderance of the evidence is against finding that the Veteran’s sleep apnea is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The September 2020 VA examiner opined it is less likely than not that sleep apnea was proximately due to, the result of, or aggravated beyond its natural progression by the Veteran’s service-connected PTSD. The examiner noted there is no anatomic or physiologic nexus to connect the conditions. Furthermore, non-service-related risk factors for the development of sleep apnea include older age, male gender, obesity, and craniofacial and upper airway abnormalities. The evidence demonstrated the Veteran to have a class three oropharynx on the Mallampati score. Moreover, the examiner opined that the cumulative effect of these risk factors is the most likely cause of the Veteran’s sleep apnea. The examiner also reviewed each of the articles submitted by the Veteran, and determined none of them actually assert PTSD or psychiatric diagnoses are a causative etiology of obstructive sleep apnea. Instead, the articles show that both obstructive sleep apnea and PTSD can adversely affect sleep, and that these conditions can exist simultaneously. Furthermore, the examiner opined there is no credible, peer-reviewed medical literature that asserts PTSD to be a causative etiology of obstructive sleep apnea. Additionally, the Veteran’s VA treatment records do not reflect complaints of poor adherence regarding PTSD as a factor in decreased compliance of a continuous positive airway pressure machine. Finally, the September 2020 VA examiner opined that the Veteran’s service-connected diabetes mellitus and peripheral neuropathy is less likely than not a causative factor in his obesity. The examiner noted that weight gain occurs when caloric intake exceeds caloric expenditure and therefore any undesired increase from an ideal body weight is most prominently secondary to volitional decisions pertaining to either the intake of calories or the frequency and/or intensity of caloric expenditure. Obesity is a multifactorial etiology due to sedentary lifestyle, inadequate exercise, poor dietary habits, and to a lesser extent, genetic predisposition. Therefore, it is less likely as not that the Veteran’s diabetes mellitus and peripheral neuropathy caused his obesity. The examiner also reviewed the articles submitted and found no nexus to connect his service-connected conditions to his obesity and therefore the examiner did not address the nexus between obesity and sleep apnea. The Veteran believes his sleep apnea is proximately due to or the result of or aggravated beyond its natural progression by a service-connected disability. The Veteran in this case is not competent to 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 pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training 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). Consequently, the Board gives more probative weight to the September 2020 VA examination and medical evidence. It is important for the Veteran to understand that the medical findings provide highly probative evidence against these claims that the Board cannot, unfortunately, ignore, outweighing the Veteran’s belief that his disabilities are the result of service, providing a highly clear basis for the opinion. For the reasons set forth above, the Board finds that the most probative evidence weighs against a finding that the Veteran’s sleep apnea is due to his military service, or to the service-connected PTSD, diabetes mellitus, and peripheral neuropathy. Thus, service connection for sleep apnea is denied. As such, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. 55-57. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Cochran, 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.