Citation Nr: 22013776 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 18-39 625 DATE: March 10, 2022 ORDER Service connection for sleep apnea associated with posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran's obstructive sleep apnea (OSA) was not secondary to his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for OSA are not met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty from June 1967 to August 1970. He was the recipient of the Purple Heart. The Veteran died while his claim was on appeal. His spouse has been substituted as the Appellant. In August 2021 and December 2021, the Board remanded this claim for further development. The argument presented by the parties is that service connection for OSA is warranted as associated with the Veteran's service-connected PTSD. In order to establish service connection on a secondary basis, there must be (1) a current non-service-connected disability, (2) a service-connected disability, and (3) evidence showing that the current non-service-connected disability is either proximately due to or the result of, or aggravated (increased in severity) beyond its natural progress by the service-connected disability. 38 C.F.R. § 3.310. Prior to passing away, the Veteran was diagnosed with OSA. The Appellant contends that the Veteran's OSA was caused by or aggravated by and/or is related to weight gain that was caused by his service-connected PTSD. Given the diagnosis of OSA and the fact that the Veteran was service-connected for PTSD, the Board finds that the first two elements for service connection on a secondary basis are met. Turning to the third element, according to a VA examiner that saw the Veteran in November 2014, his PTSD did not cause OSA. Then, in November 2020, another VA examiner opined that there was no objective evidence that the Veteran's OSA was aggravated by his PTSD with alcohol use disorder. In May 2021, a VA examiner stated OSA is not caused by or related to PTSD with alcohol use disorder and unspecified major neurocognitive disorder. The examiner stated that although there is some medical that suggests PTSD increases the risk of sleep apnea, PTSD is not associated with the etiologic development of sleep apnea. Moreover, the examiner found that there had been no aggravation of the Veteran's OSA since a sleep study in 2013. The examiner concluded this because the Veteran did not require any additional treatment for his OSA, other than the continued use of his continuous positive airway pressure (CPAP) machine. In June 2021, another VA examiner echoed the prior examiners and added that the literature provided by the Veteran does not show a direct etiological association of sleep apnea by tobacco or alcohol use. In September 2021, another VA examiner stated that PTSD with alcohol use disorder and unspecified major neurocognitive disorder did not cause or aggravate OSA. The examiner added that there is no physiologic or anatomic mechanism by which psychological conditions can cause or aggravate OSA. This analysis included the effects of medications used to treat related psychological comorbidities. The examiner added that the Veteran had been obese for such a long period prior to being diagnosed with sleep apnea that the Veteran's OSA was not related to his weight, even though obesity constitutes a risk factor. Moreover, there was no evidence in the record that the Veteran's psychological condition caused weight gain. Further supporting his opinion, the examiner stated that it is more likely than not that the Veteran would have developed OSA even in the absence of obesity and that obesity cannot necessarily be attributed to any one factor, such as PTSD. In December 2021, another VA examiner echoed the sentiments of prior VA examiners. The December 2021 VA examiner wrote that medical literature does not support a physiologic, biomechanical, or anatomic mechanism for PTSD with alcohol use disorder to cause or permanently aggravate obesity or sleep apnea beyond its natural progression. The examiner added that mental health conditions do not preclude exercise and, therefore, do not cause obesity. The examiner then went onto discount cohort studies that do not show causality and articles from the National Sleep Foundation. Combined, the medical opinions create a persuasive picture that the Veteran's PTSD did not cause obesity and did not cause OSA. Moreover, the examiners' opinions demonstrate that even if obesity was caused by a service-connected disability, it would not cause OSA. To the extent that the Appellant contends that the Veteran's OSA was due to a service-connected disability, the Board finds that whether such a relationship exists constitutes a complex medical question outside the realm of common knowledge of a lay person diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Considering the pertinent evidence in light of the governing legal authority, the Board finds that the evidence is persuasively against the claim. In reaching this decision the Board considered the doctrine of reasonable doubt, however, the doctrine is not for application and the claim must be denied. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Chalker, 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.