Citation Nr: 21031447 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 16-39 099 DATE: May 21, 2021 ORDER Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD) or diabetes mellitus, type II, is denied. FINDING OF FACT The Veteran's sleep apnea is not secondary to his service-connected PTSD or diabetes mellitus, type II, and is not otherwise etiologically related to his active duty military service. CONCLUSION OF LAW The criteria for entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD or diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Air Force from August 1964 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which denied entitlement to service connection for sleep apnea, including as secondary to the Veteran's service-connected PTSD and diabetes mellitus, type II. The Veteran timely appealed. In November 2019, the Veteran and his spouse testified before the undersigned Veterans Law Judge in a videoconference hearing concerning the Veteran's claim. A copy of the hearing transcript is of record. The Board remanded the issue on appeal in February 2020 and in November 2020 for additional evidentiary development. The development has been completed and the case has been appropriately returned to the Board for adjudication. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD or diabetes mellitus, type II, is denied. The Veteran maintains entitlement to service connection for sleep apnea which he believes is attributable either to his service-connected PTSD or diabetes mellitus, type II. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.§§ 1110, 1131; 38 C.F.R. § 3.303. Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. Secondary service connection generally requires (1) a current disability; (2) a service-connected disability; and (3) a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.§ 5107; see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). At the outset, the Board notes that the Veteran was diagnosed with sleep apnea based on an April 2014 sleep study, so the first element of the secondary service connection claim is established. The Veteran is also service-connected for both PTSD and diabetes mellitus, type II, thereby satisfying the second element for secondary service connection. At issue is whether the Veteran's sleep apnea is caused or aggravated by either or both service-connected conditions. In support of his claims, the Veteran submitted medical treatise evidence. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159 (a)(1). In this regard, the Board notes that treatise evidence must "not simply provide speculative generic statements not relevant to the Veteran's claim." Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, "standing alone," must discuss "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." Id. (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). The Veteran submitted an article from Everyday Health discussing the high incidence of sleep apnea in anxiety disorders. The author found that many people who had anxiety disorders, including PTSD, had preexisting sleep apnea that effectively set them up to later develop anxiety disorders, as the presence of increased levels of stress hormones due to the apnea made it more difficult to deal with life's stresses or severe psychological trauma. The Board observes that this article does not support the Veteran's claim that his sleep apnea is caused by his service-connected PTSD, as it essentially argues the opposite: that sleep apnea is often a precursor to PTSD. As such, the Board finds that it is of no probative value concerning the etiological relationship between the Veteran's sleep apnea and his service-connected PTSD. He also proffered an article from The National Center for Post-Traumatic Stress Disorder Research Quarterly, detailing correlations between fear (PTSD and other psychiatric disabilities) and sleep systems in the brain. In the October 2020 and May 2021 Informal Hearing Presentations (IHP), the Veteran submitted links to additional articles that supported the assertion that there is an increased prevalence of sleep apnea in people with certain psychiatric disabilities, including PTSD. The May 2021 IHP also included a link to an article concerning the common occurrence of sleep apnea in patients with type II diabetes. The Board has considered the submitted medical treatise evidence and, while it provides general information about sleep apnea and PTSD and sleep apnea and diabetes, type II with some correlative data, it does not provide a clear nexus, nor does it provide a specific opinion as to the etiology of the Veteran's sleep apnea. Therefore, the articles hold low probative value for the purpose of adjudicating the claim. In March 2020, the Veteran underwent a VA examination. There, an examiner determined that the Veteran's claimed sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, including PTSD and diabetes mellitus, type II. The examiner reasoned that obstructive sleep apnea is a physiological disorder causing a narrow pharyngeal cross-section and psychological conditions such as PTSD do not cause a narrow pharyngeal cross-section. She detailed the risk factors for sleep apnea, including obesity, male gender, large neck circumference, maxillomandibular abnormalities, increased volume of soft tissues, family history of sleep apnea, chronic snoring, hypothyroidism, Down syndrome, mucopolysaccharidoses, increasing age, Black, Hispanic, or Asian ethnicity, and tobacco smoking. She cited a study from the Journal of Clinical Sleep Medicine that concluded that veterans with PTSD screened as high risk for sleep apnea at much higher rates than those seen in community studies and acknowledged the statistical correlation between the two. However, she observed that this evidence did not demonstrate a causal correlation, as there is no mechanism put forth or pathophysiology explained for PTSD as an underlying etiology for sleep apnea. The examiner found no medical literature showing PTSD as a direct cause for sleep apnea, nor did she locate research that showed diabetes as associated or a risk factor for its development. Concerning whether the Veteran's sleep apnea was aggravated by his service-connected PTSD or diabetes mellitus, type II, the examiner found that it was not. She noted that recent medical records found his diabetes mellitus type II was well controlled. The examiner again noted that sleep apnea is a physiological disorder causing a narrow pharyngeal cross-section. While she acknowledged that diabetes and sleep apnea often coexist in the setting of shared risk factors and perhaps a similar metabolic environment, there was no medical research to suggest that sleep apnea was aggravated by diabetes mellitus, type II. Additionally, she noted the absence of medical research to shown that sleep apnea is aggravated by PTSD. The Board finds the March 2020 medical opinion highly probative as to whether the Veteran's sleep apnea is caused by or aggravated by his service-connected PTSD or service-connected diabetes mellitus, type II, as the examiner reviewed the claims file, interviewed the Veteran, and provided a clinical evaluation of him before proffering an opinion that cites to relevant medical research, is well reasoned, and fully articulated. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges the Veteran's sincere belief that his sleep apnea is secondary to his service-connected PTSD or diabetes mellitus, type II. However, any opinion regarding whether sleep apnea is related to PTSD or diabetes mellitus, type II requires specialized knowledge and expertise as it is a complex medical issue. The Veteran, as a lay person, is not shown to possess the requisite specialized training in the medical field. Thus, his opinion as to the etiology of his current sleep apnea is not competent evidence and the Board instead relies on the objective medical evidence of record, including the probative March 2020 medical opinion, in determining that service connection is not warranted on a secondary basis. Although the Veteran specifically claims sleep apnea as secondary to his service-connected PTSD or diabetes mellitus, type II, VA must explore all potential avenues for service connection. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that a veteran is not precluded from establishing service connection with proof of actual direct causation). As discussed above, the Veteran has a current diagnosis of sleep apnea, thus satisfying the first element for service connection on a direct basis. However, his service treatment records (STRs) are negative for any complaint, treatment, or diagnosis of a sleep apnea disorder, daytime fatigue, elevated blood pressure, weight gain, apneas, snoring, morning headaches, numerous awakenings during the night, or other possible indicia of sleep apnea. Thus, the Veteran's STRs provide no evidence in support of the in-service incurrence of a sleep apnea disorder. See 38 C.F.R. § 3.303. Further, the VA medical opinion obtained in March 2021 specifically concerning direct service connection indicates that the Veteran's disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran was first diagnosed with the condition over forty years after his active duty service and that he had responded "no" to frequent trouble sleeping at separation. She concluded that there was no objective evidence to support a finding that the Veteran's sleep apnea began while in service. The Board finds this opinion highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided a clinical evaluation of him prior to proffering an opinion that is well reasoned and aligns with the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges the Veteran and his spouse's testimony that he has experienced symptoms of this disability, including snoring and breathing cessation, at least since the late 1980s (at the hearing, the Veteran's spouse testified that she observed his difficulties breathing during the course of their 30 year marriage, placing onset around 1989). They are competent to describe this. However, any opinion regarding whether this disability is directly related to the Veteran's military service requires specialized knowledge and expertise as it is a complex medical issue. The Veteran, his spouse, and representative are not shown to possess the requisite specialized training in the medical field to proffer such an opinion. Thus, their opinions as to the etiology of his current sleep apnea is not competent evidence and the Board instead relies on the objective medical evidence of record, including the probative March 2021 medical opinion, in determining that service connection is not warranted on a direct basis. Additionally, sleep apnea is not listed as an enumerated "chronic disease" under 38 C.F.R. § 3.309 (a); therefore, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303 (b) do not apply here. Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013. For all the reasons discussed above, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for sleep apnea as secondary to the service-connected PTSD or service-connected diabetes mellitus, type II, and there is no evidence to support a finding that his sleep apnea is directly attributable to his active duty service. Thus, as the preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim is denied. 38 U.S.C. § 5107. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Bush 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.