Citation Nr: 21031327 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 17-61 087 DATE: May 21, 2021 ORDER Service connection for obstructive sleep apnea (OSA) is denied. FINDINGS OF FACT 1. The Veteran had active service from March 1966 to January 1968. 2. OSA was not shown in service, is not causally or etiologically related to service, and was not caused by or permanently worsened in severity by a service-connected disability. CONCLUSION OF LAW OSA was not incurred in service and is not proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Turning to the medical evidence, VA examinations and clinical treatment records reflect that the Veteran has been diagnosed with OSA. As such, a current diagnosis has been shown and the first element of service connection has been met. As to in-service incurrence, the service treatment records (STRs) do not show complaints of, treatment for, or a diagnosis of a sleep disorder during service. Importantly, the December 1967 separation examination did not include a diagnosis of OSA, and the Report of Medical History indicated no frequent trouble sleeping or symptoms associated with OSA. Accordingly, the medical evidence does not support the in-service incurrence of OSA. To the extent that the Veteran asserts a causal relationship between service and current diagnosis of OSA, a January 2020 VA examiner found that OSA was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He noted that OSA was an anatomic and physiologic condition of the oropharynx which began in 2012. As this was many years after separation from service, the examiner concluded that OSA was not caused by service and was not incurred therein. Therefore, the medical evidence does not support service connection on a direct basis. Next, the Veteran's main contention is that OSA is secondary to service-connected posttraumatic stress disorder (PTSD). As he has a current diagnosis of OSA and is already service-connected for PTSD, the first two elements of secondary service connection have been met. As to medical nexus, a June 2017 VA examiner opined it was less likely than not that OSA was proximately due to or the result of the Veteran's service-connected PTSD. He stated that OSA was the most common type of apnea and was caused by a relaxation of the posterior musculature in the oropharynx during sleep. In addition, the examiner explained that OSA was more common with aging and in overweight males. Next, the examiner stated that the current medical literature does not support a causative relationship between PTSD and the development of OSA. He noted that an association between the two conditions had been shown in multiple medical studies, but a causative nature has not been made clear. Accordingly, he concluded it was less likely than not that OSA was due to a psychiatric diagnosis of PTSD. Further, a January 2020 VA examiner reported that he could not determine a baseline level of severity of OSA. In addition, he also opined that OSA was less likely than not aggravated beyond its natural progression by service-connected PTSD. He explained that OSA was a physiologic and anatomical condition that involved the oropharynx which was not caused by any psychiatric condition. While he noted that PTSD could lead to poor sleep quality, he clarified that poor sleep quality was not the same as OSA. Next, the examiner discussed relevant medical articles which reported an increased prevalence of OSA in patients with PTSD and other psychiatric disorders. However, he explained that these studies did not draw a causative relationship between PTSD and OSA; rather, they drew attention to the fact that individuals with psychiatric conditions had increased prevalence of OSA. As such, he concluded that OSA was not related to service, including PTSD, since there is no conclusive evidence of a causative relationship between psychiatric disorders and OSA. In sum, the medical evidence does not support a causal link between OSA and service-connected PTSD. Therefore, the medical evidence does not support service connection on a secondary basis. In support of the appeal, the Veteran submitted several internet articles. Briefly, one discussed a study evaluating veterans with PTSD for OSA, one from the sleep foundation noted that those who were being evaluated for PTSD were found at higher risk for OSA, one from a veteran's publication commented that OSA was the most prevalent service-connected respiratory disability, and one found that OSA treatment improved PTSD symptoms. Treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). Significantly however, treatise materials generally are not specific enough to show nexus, id. at 317, and that medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993). In this situation, the VA examinations addressed the Veteran's specific case with references to his specific treatment, which is more probative than generic treatise evidence. Further, while medical treatise evidence can provide important support when combined with an opinion of a medical professional, such a medical nexus has not been provided. Mattern v. West, 12 Vet. App. 222, 228 (1999). Rather, the articles provided only a brief overview of the research studies without specifics to this Veteran's situation nor were the complete research studies of record. As such, this evidence is not dispositive, is assigned lesser probative value, and does not outweigh the findings of the VA examinations which were based on a specific examination of this Veteran. The Board has considered the Veteran's lay statements that his disorder was caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matters involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Kokolas, 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.