Citation Nr: 21027564 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-33 822 DATE: May 6, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is denied. FINDING OF FACT OSA did not have its onset during the Veteran's active service and is not otherwise etiologically related to such service, and is not caused or chronically worsened by a service-connected disability, to specifically include posttraumatic stress disorder (PTSD) with insomnia disorder and any medication prescribed for treatment of such. CONCLUSION OF LAW The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active naval service from September 1971 to September 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by a Veterans Affairs (VA) Regional Office (RO). In connection with this appeal, the Veteran and his wife testified at a hearing before the undersigned Veterans Law Judge in March 2020. In June 2020, the Board remanded the Veteran's claim for additional development. The Board notes that additional evidence was associated with the claims file subsequent to the February 2021 supplemental statement of the case (SSOC). However, the evidence is unrelated to the issue on appeal and the Veteran is not prejudiced by the Board's adjudication of the issue decided herein. The Veteran has asserted that his OSA is secondary to his service-connected PTSD with insomnia disorder. Additionally, he reported that his OSA has continued since 2016 despite his sixty-pound weight loss. A review of post-service medical records reflect that the Veteran underwent several private sleep studies and was diagnosed with OSA as early as June 2010. In July 2014, the Veteran was afforded a VA examination. The examiner opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service-connected PTSD with insomnia disorder. Although the Veteran had a sleep problem, the examiner stated that it was difficult to sort out what awakened the Veteran. Even with treatment for OSA, the Veteran still had problems with his sleep suggesting that other issues (such as anxiety and dyspnea due to other conditions) were a major factor. He added that the Veteran's OSA was most likely due to his fifty-pound weight gain since service. The Veteran was provided an additional VA examination in April 2019. The examiner determined that the Veteran had an Apnea Hypopnea Index (AHI) baseline of 20 following a private sleep study in 2013. He opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service-connected PTSD with insomnia disorder. Additionally, he opined that the Veteran's OSA was less as likely as not aggravated beyond its natural progression. He noted that not all patients with PTSD or insomnia had OSA. He stated that the Veteran's PTSD would not necessarily cause a more severe sleep apnea with an AHI of 74.8 as reported by private sleep study in 2017. He suggested that medications (such as Ambien and Lunestra) used to treat the Veteran's insomnia disorder could make sleep apnea worse. He stated that the Veteran's insomnia may be aggravated by PTSD; however, the Veteran's OSA was not affected by his PTSD alone. He found that the Veteran was at risk for OSA due to mild micrognathia, Mallampati score of three (3), age, and genetic predisposition. Further, he questioned the validity of the AHI result from the September 2017 private sleep study and recommended that the sleep study be redone. A private sleep study was performed at Kaiser Permanente in May 2020 revealed an AHI of 61. An opinion was obtained from a VA examiner in October 2020. The clinician reviewed the claims file and opined that OSA was less likely than not proximately due to or the result of the Veteran's service-connected PTSD with insomnia, to include any medications. The examiner noted that the Veteran was initially diagnosed with PTSD in 2013 and was noted to be in the presence of obesity at the time of the diagnosis. The examiner stated that given that obesity is the leading risk factor in developing OSA, the age of the Veteran at the time of onset, noted neck circumference, and micrognathia, it is likely those anatomic and physiologic factors are the etiology of OSA. The examiner noted that although the Veteran lost weight and continues to have OSA (as noted in the 2017 and 2020 studies), the Veteran continues to be overweight which is still a risk factor for the condition. Additionally, PTSD, insomnia, and the medications used to treat the Veteran's insomnia and PTSD are not known to cause OSA. The examiner concluded that there are no described pathophysiologic mechanisms to cause OSA. The examiner also opined that OSA is not at least as likely as not aggravated beyond its natural progression by the service-connected PTSD with insomnia disorder, to include any medications. The clinician indicated that the medical records do not support actual worsening of the Veteran's OSA by the service-connected PTSD with insomnia disorder, to include any medications. The examiner indicated that there was significant improvement in the Veteran's OSA in 2018 when good compliance was noted with treatment with the CPAP (continuous positive airway pressure) machine when AHI was within target at 10.7. However, other records show that in June 2019 there was decreased compliance with the use of the CPAP machine and worsening of the Veteran's condition. The examiner concluded that this is not indicative of worsening due to the underlying psychiatric condition, or medication related to it, but decreased compliance with CPAP use which caused the worsening of the condition. In this case, the Board finds the most probative evidence weighs against the claim. With regard to direct service connection, OSA was not diagnosed until June 2010, more than thirty years after the Veteran separated from service. Moreover, there is no medical evidence linking OSA to service. With regard to secondary service connection, the most probative evidence of record, the opinions of the 2014 and 2020 VA examiners' opinions which indicates that the Veteran's OSA was not caused or aggravated by the service-connected PTSD with insomnia, including medications used to treat PTSD and insomnia. Although the 2019 VA examiner suggested that the medication used to treat insomnia may aggravate OSA, the examiner indicated that the Veteran's OSA was not affected by his PTSD alone. Consequently, the Board finds the April 2019 opinion to be of little probative value. However, the 2014 and 2020 VA examiners based their opinions on the relevant medical evidence and lay statements, and provided rationale for the opinions. Therefore, the Board finds the 2014 and 2019 VA examiners' opinions significantly probative. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnosis and etiology in this case extends beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. (Continued on the next page) Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for OSA is not warranted. 38 U.S.C. § 5107(b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Cryan, 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.