Citation Nr: 21030534 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 15-05 382 DATE: May 19, 2021 ORDER Entitlement to service connection for a sleep disorder to include sleep apnea, secondary to service-connected disabilities is denied. FINDING OF FACT The most probative evidence supports that the Veteran's sleep disorder to include sleep apnea is not related to service nor caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for sleep disorder to include sleep apnea have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 2001 to November 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was last before the Board in February 2021, when it was remanded for further development. Entitlement to service connection for a sleep disorder to include sleep apnea, secondary to service-connected disabilities The Veteran contends that his claimed sleep disorder to include sleep apnea is etiologically related to his service-connected posttraumatic stress disorder (PTSD) and/or his service-connected left knee disability due to weight gain. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, to prove service connection there must be: (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 established for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (2020). As an initial matter, the Veteran has a current diagnosis of obstructive sleep apnea. Thus, the question for the Board is whether the Veteran's current sleep apnea is related to service or his service-connected disabilities. Service treatment records show no diagnosis of, or treatment for, sleep disorder to include sleep apnea during service. On his separation report of medical history dated in August 2005, the Veteran indicated "no" shortness of breath and "yes" for having trouble sleep. He explained that the "majority of his "yes" are related to his left knee surgery and tonsilitis" and the accompanying physical examination revealed no abnormalities. Thereafter, the record shows no complaints of symptoms prompting a treatment provider to order a sleep study until June 2010, which is more than four years after separation from service. In September 2010, the Veteran was afforded a sleep study. The sleep study reported that the Veteran has a history of snoring, excessive daytime sleepiness, and anxiety with PTSD. Comorbid problems include chronic joint pain and lower leg pain for which he takes daily narcotic medications. He complains that when he does not take pain medication or runs out of medication, his sleep is more problematic with pain interfering with sleep. The Veteran's PTSD have been characterized by symptoms that include chronic sleep impairment. The September 2010 sleep study impression notes "moderately severe sleep-disordered breathing in an obese man with a body mass index of 37 and a history of PTSD. The Veteran was afforded a VA examination in November 2019. The examiner confirmed that the Veteran is diagnosed with obstructive sleep apnea (OSA) and opined that the condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner notes that the Veteran's service treatment records show sleep problems in the context of stress and worry, but symptoms or diagnosis or sleep apnea is not suggested by the available records at that time. The examiner also opined that the condition is less likely than not proximately due to or the result of the Veteran's service-connected PTSD or left knee disability. She notes that PTSD is not a known risk factor for sleep apnea. She explains that more likely, it is due to the recognized risk factors such as high body mass index (BMI) and large neck circumference. The examiner notes that the Veteran is on no medications which would affect sleep function. In regard to the Veteran's left knee, the examiner noted that the Veteran is not taking any medication for pain that would impair breathing and or sleep. Prior use of narcotics years ago would not be the cause of ongoing sleep impairment. Pain from the knee condition may well be causing him to wake up at night, but is unlikely to be the cause of OSA, as pain is not a known cause or risk factor for OSA. The examiner further notes that the Veteran has multiple causes of sleep disruption, most notably knee pain and nightmares. It is likely that OSA is also contributing to a mild/moderate degree to his sleep impairment. The matter was remanded in February 2021 for an examiner to discuss the Veteran's contention that his service-connected disabilities caused weight-gain resulting in the claimed sleep disorder. In February 2021, a VA examiner opined that sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner notes that the records document that the Veteran had a sleep study in 2010 that identified sleep apnea. Further review documents that obstructive sleep apnea is the primary sleep disorder, based on sleep study results. It is also noted that the Veteran was found to have central apnea component during CPAP trials in 2011 but was on narcotic medication, which can cause central sleep apnea at that time. The examiner notes that narcotic medications were discontinued in late 2018 per records. Another sleep study was recommended in Aug 2017; however, this was not completed. The February 2021 VA examiner also notes that the Veteran's service-connected left knee with scar, and service-connected spine condition are orthopedic conditions. She explains that Orthopedic conditions do not cause OSA or central/complex sleep apnea. There is no basis in medical fact, no medical rationale, to support that these service-connected conditions contribute to the Veteran's sleep apnea condition. A skin scar is also completely unrelated to sleep apnea and there is no medical rationale that a skin scar is connected to sleep apnea in any way. Pain due to service-connected conditions may disrupt sleep; however, this is not the same as sleep apnea that is diagnosed by a sleep study. Pain does not cause sleep apnea. In regard to whether the Veteran's service connected PTSD could have caused the condition, the February 2021 examiner opines that although some studies have demonstrated an association of PTSD and OSA, this does not confirm causality of one condition by the other. A causal association between PTSD and OSA is not supported in the medical literature. Specifically, the literature does not support that PTSD causes OSA. Although the conditions may occur together and reported sleep symptoms may overlap between OSA and PTSD, these two conditions are medically distinguishable from the other and have separate diagnostic criteria. The diagnosis of OSA/sleep apnea requires a sleep study and is a medically separate condition from PTSD. The examiner notes that OSA/sleep apnea is due to intermittent upper airway obstruction caused by anatomic factors and is not due to PTSD, or orthopedic or skin conditions. She explains that OSA risk factors in this Veteran include the Veteran's inherent craniofacial and upper airway anatomy, habitus, aging, and male gender. These risk factors are the more likely contributory factors to the OSA condition. The above service connected conditions are also not risk factors for central sleep apnea. The examiner also notes that narcotic use can contribute to central sleep apnea, and Veteran was prescribed narcotics at the time central sleep apnea component was identified in 2011. However, the Veteran is no longer on narcotic medications. Also, narcotic medications are not a supported treatment modality for chronic pain from the service-connected orthopedic conditions. Narcotic medication use in Veteran is no longer documented. In regard to whether the Veteran's service-connected conditions aggravated his OSA, the February 2021 VA examiner opined that there is no aggravation of OSA, or sleep apnea and or complex sleep apnea identified. Records do not support aggravation of OSA/sleep apnea condition. The examiner explains that the records document that Veteran is not using CPAP/BiPAP and also has had weight loss and cessation of narcotic usage. She explains that both weight loss and stopping narcotics would cause improvement of sleep apnea and worsening of any of the sleep apnea condition is not document. The February 2021 remand directed an examiner to also clarify whether weight-gain has caused or aggravated the claimed sleep disorder. The February 2021 VA examiner opined that it is less likely than not that the weight-gain was caused or aggravated, at least in part, by any of the Veteran's service-connected disabilities. She provided the rationale that there is no aggravation of the sleep apnea condition identified; weight-gain did not aggravate the sleep apnea condition, because records support that the Veteran has had documented weight loss since 2011 when he had the sleep study. Also, the causes of weight gain are multifactorial and complex, and it is not possible to attribute weight gain or obesity to a specific condition or medication. The examiner explains that many factors contribute to weight gain such that it is not possible to determine what is the cause of the prior weight gain in this Veteran. Factors such as genetics, other health conditions, lifestyle and or behavioral factors, other medications, and dietary factors are all contributory to weight and weight gain. Therefore, the increased weight/BMI in this Veteran cannot be attributed to any one or specific condition or medication, or to any service connected condition. Upon review of the record, the Board finds that the most probative evidence is against the claim. The Board finds the VA examiners' opinions, combined, are highly probative and entitled to great weight. The examiners reviewed the claims file, examined the relevant facts, and provided reasoned and detailed rationale for the conclusions reached that included citing to medical literature. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, these opinions combined are highly probative and persuasive and support a finding that the Veteran's sleep disorder to include sleep apnea is not related to service nor caused or aggravated by a service-connected disability. Finally, to the extent that the Veteran and his representative believe that his current disability is related to service and/or his service connected disabilities, as lay persons, they have not shown that they have specialized training sufficient to render such an opinion. In this regard, the diagnosis and etiology of sleep apnea, and the relationship between other conditions and sleep apnea, are matters that requires medical training and expertise to determine. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Thus, the Board finds the combined opinions of the VA examiners to be significantly more probative than the lay assertions. In sum, the most probative evidence is against the claim, and service connection for sleep disorder to include sleep apnea is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Asare, 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.