Citation Nr: 21030142 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 14-28 581 DATE: May 17, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The probative medical evidence indicates the Veteran's current OSA was not caused or aggravated by his service-connected PTSD and is not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for OSA, to include as secondary to PTSD have not been met. 38 U.S.C. §§ 1110, 5107 (b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from June 1991 to November 1991, from February 2003 to August 2003, and from January 2012 to February 2014. In February 2021, The Board of Veterans' Appeals (Board) remanded this matter for an additional medical opinion, which was completed in March 2021. Review of the completed development reveals that substantial compliance with the remand directives was obtained. Stegall v. West, 11 Vet. App. 268 (1998). Service connection for OSA Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish entitlement to service-connected compensation benefits, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be established on a secondary basis for disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); Allen v. Brown, 8 Vet. App. 374 (1995). To prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. The VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). OSA is a specific medical condition defined as the "cessation of breathing resulting from the collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep." See Dorland's Illustrated Medical Dictionary 116-17 (32nd ed. 2012). Entitlement to service connection for sleep apnea, to include as secondary to PTSD. The Veteran was diagnosed with OSA following a March 2010 VA sleep study. The Veteran contends that his sleep apnea was aggravated during his January 2012 to February 2014 period of active duty military service. Alternatively, he contends that his sleep apnea is secondary to his service-connected PTSD. The Veteran's service treatment records (STRs) are silent for treatment of OSA or related symptoms prior to or during active service. It is listed as a present disorder during his last period of service, but it is not shown that any treatment was rendered or that it was significantly disabling. In an October 2018 medical opinion, a VA medical examiner opines that the Veteran's OSA was less likely than not caused by his PTSD. The examiner noted that risk factors of OSA include being male, overweight and over the age of 40. The Veteran was 51 years old at the time, morbidly obese, and had previously been diagnosed with hypertension, diabetes mellitus, and the prescribed CPAP was not as effective as previously. A sleep study was requested and completed in November 2018, revealing severe OSA. A 2019 contract examiner assessed OSA but provided negative opinions that it was less likely than not related to an in-service event, was aggravated beyond normal progression, or was due to or caused by the Veteran's service-connected PTSD. The Veteran's OSA was first evaluated in 2009 and ultimately diagnosed prior to active duty service, as noted in 2011. The examiner went on to suggest that there is no evidence to support onset for sleep apnea during prior active duty service. The examiner defined OSA as an obstructive phenomenon, with the single most important predisposing element being BMI. There is no evidence for OSA rising during active duty periods. Though a relationship between PTSD and OSA is noted in literature, no cause and effect had been established by the examiner; therefore, it is unlikely that a secondary service connection exists between PTSD and OSA. The examiner further reports not being able to establish a baseline level of severity based upon review of medical evidence available but opines that the Veteran's OSA is less likely than not aggravated beyond normal progression by his service-connected PTSD. The physician explained that obesity is the major cause of OSA and concluded the Veteran's history of obesity was the most likely cause of his OSA. The physician acknowledged that medical studies have suggested an increased incidence of OSA in patients with PTSD, but he was not aware of any medical literature establishing a causal relationship between the two conditions. The March 2021 examiner was asked whether or not this condition worsened in severity during the period of active service from January 2012 to February 2014. The clinician found the condition was not worsened beyond its natural progression during the period in question. The rationale provided centered around the Veteran's Apnea-Hypopnea Index (AHI): it was 17.1 in December 2011 when he was diagnosed with sleep apnea (15-30 is considered to be of moderate severity). The Veteran was accordingly prescribed the use of a c-pap. At the time of the Veteran's March 2013 C&P exam, he stated that the sleep apnea was asymptomatic with use of this prescribed c-pap at 11cm H2O. He denied any daytime sleepiness at this time. Though a decreased efficacy of the c-pap was not noted until 2018, at which time the machine required an adjustment in pressure, the examiner concluded that the Veteran's OSA was less likely than not permanently aggravated beyond its natural progression. Conclusion In light of the above, the Board determines that a preponderance of the evidence shows that the Veteran's OSA was not incurred in or aggravated by service nor was it caused or aggravated by his service-connected PTSD. The March 2021 examiner provided a comprehensive opinion after review of all the pertinent evidence. Reference was made to pertinent studies, statements, and clinical history. This is, in the Board's view, persuasive, especially with consideration given to the entire record. For the above reasons, the Veteran's claim is denied. In reaching this decision the Board has considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C. § 5107. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Omosegbon, Babalakin O. 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.