SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran, who served from August 1990 to August 1994, appeals the denial of service connection for obstructive sleep apnea (OSA). The veteran is currently 100 percent disabled and receives special monthly compensation (SMC). The Board found that OSA was not incurred in service, nor is it causally or etiologically related to service or aggravated by a service-connected disability. The service treatment records (STRs) did not reflect any in-service complaints, treatment, or diagnosis of OSA or sleep problems, and the veteran did not contend that OSA symptoms began during service. The veteran argued that service-connected PTSD caused or aggravated OSA, with obesity as an intermediate step. Two private medical opinions concluded it was at least as likely as not that OSA resulted from PTSD-related weight gain and obesity, citing research and the Veteran's progressive weight gain. However, the Board found these opinions flawed, noting they misidentified the Veteran's medication (buspirone) as a benzodiazepine causing weight gain, when it is not and may even cause weight loss. The Board also noted the Veteran's significant weight gain began during service, predating PTSD diagnosis and buspirone prescription. VA examiners concluded that OSA is multifactorial and not directly caused or aggravated by PTSD, and that the Veteran's weight gain predated PTSD and buspirone prescription. The Board gave less weight to the private opinions due to factual inaccuracies and lack of specificity, and more weight to the VA examinations. Service connection for OSA was denied.

Rationale

STRs do not reflect in-service complaints or diagnosis of OSA.; Veteran did not contend OSA symptoms began during service.; Private opinions flawed due to misidentification of medication side effects and timing of weight gain.; VA examiners found OSA multifactorial and not directly caused/aggravated by PTSD.; Weight gain predated PTSD diagnosis and buspirone prescription.

Full Decision Text

Citation Nr: A24079117
Decision Date: 11/29/24	Archive Date: 11/29/24

DOCKET NO. 230113-314485
DATE: November 29, 2024

ORDER

Service connection for obstructive sleep apnea (OSA) is denied.

FINDINGS OF FACT

1. The Veteran served on active duty from August 1990 to August 1994. He has been 100 percent disabled since March 2023 plus in receipt of special monthly compensation (SMC).

2. OSA was not shown in service, is not causally or etiologically related to service, and was not caused by or worsened in severity by a service-connected disability.

CONCLUSION OF LAW

OSA was not incurred in service and is not caused by, 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 (2024).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

This decision has been written under the guidelines of the Veterans Appeals Improvement and Modernization Act, also known as the Appeals Modernization Act (AMA). The Veteran filed an initial claim in August 2020, which agency of original jurisdiction (AOJ) denied in September 2020. 

The Veteran subsequently filed requests for Higher-Level Review (HLRs) in March and August 2022, and the claim was again denied. In January 2023, he appealed to the Board via a VA Form 10182 and elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ decision on appeal. 38 C.F.R. § 20.301. 

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, caused by, 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, the Veteran was diagnosed with mild OSA in a February 2020 VA sleep study. As such, the first element of service connection has been met. As to in-service incurrence, the service treatment records (STRs) do not reflect complaints of, treatment for, or a diagnosis of OSA or any sleep problems. Moreover, the Veteran does not contend that the symptoms of OSA began during service. As such, the medical evidence does not support service connection on a direct basis.

Next, as to secondary service connection, the Veteran asserts that service connected posttraumatic stress disorder (PTSD) caused or aggravated OSA. As noted, he has been diagnosed with OSA and has been service connected for PTSD since June 2010, which meets the first two elements of secondary service connection.

As to a medical nexus between PTSD and OSA, a May 2021 VA examiner concluded that it was less likely than not that OSA was related to the PTSD. In support of this conclusion, the examiner reasoned that OSA tended to be multifactorial in nature, including genetic factors, environmental factors, drug abuse, lifestyles, body habitus, sinus conditions, upper respiratory conditions, neurological deficit and/or idiopathic. 

Thus, the examiner concluded that there was no direct causality of PTSD causing or leading to OSA. Further, the examiner indicated that although sleep difficulty is one of the many PTSD symptoms, PTSD is not a contributing factor (i.e., aggravation) or cause of OSA. There is no contrary medical opinions, and the medical evidence does not support secondary service connection based on PTSD causing or aggravating O
 that it was less likely than not that OSA was related to the PTSD. In support of this conclusion, the examiner reasoned that OSA tended to be multifactorial in nature, including genetic factors, environmental factors, drug abuse, lifestyles, body habitus, sinus conditions, upper respiratory conditions, neurological deficit and/or idiopathic. 

Thus, the examiner concluded that there was no direct causality of PTSD causing or leading to OSA. Further, the examiner indicated that although sleep difficulty is one of the many PTSD symptoms, PTSD is not a contributing factor (i.e., aggravation) or cause of OSA. There is no contrary medical opinions, and the medical evidence does not support secondary service connection based on PTSD causing or aggravating OSA.

Next, the Veteran's initial contention was that service-connected PTSD caused obesity, which in turn caused OSA. In this regard, obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a).

In support of the claim, the Veteran submitted two private medical opinions in August 2020 and March 2021. The August 2020 consultant, a nurse practitioner, concluded that it was at least as likely as not that the Veteran's weight gain and obesity were due to or related to service-connected PTSD and that it was at least as likely as not that the OSA resulted from the weight gain and obesity and that the OSA would not have occurred without the weight gain and obesity.

In support of these conclusions, the August 2020 consultant discussed research correlating PTSD with weight gain, including due to medication, and with OSA. It was noted the Veteran's weight has progressively increased from service entry when he weighed 170 pounds to separation, weight 205 pounds, and to his then current weight of 275 pounds. Further, VA treatment records note a maximum weight of 299 pounds in August 2021.

The consultant indicated the evidence of progressive weight gain and a current obesity chronologically developed after the mental health stressors with mental health medication that had known pharmacology to promote weight gain. Significantly, the August 2020 consultant noted the Veteran had been prescribed buspirone (BuSpar) for PTSD, which according to the VA treatment records was originally prescribed in October 2019. This examiner indicated that an adverse side effect of buspirone, a benzodiazepine, was weight gain. 

However, according to the National Institutes of Health (NIH), National Library of Medicine, weight gain is not a prevalent adverse side effect of buspirone. See https://www.ncbi.nlm.nih.gov/books/NBK531477/. Instead, according to NIH research, buspirone may induce weight loss. See https://pmc.ncbi.nlm.nih.gov/ articles/PMC10164918/. 

Also, the Veteran's progressive weight gain began during active duty when he gained approximately 35 pounds, and at separation the BMI was 30 indicating he was obese at that time, 16 years prior to being diagnosed with PTSD and 25 years prior to being prescribed buspirone and being diagnosed with OSA. A common internet search reflects that obesity is considered with a BMI of 30 or greater. https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm

Next, the March 2021 consultant, a physician's assistant, similarly concluded that it was at least as likely as not that OSA was secondary to PTSD with sleep disturbances and weight gain/obesity. In support of this conclusion, the March 2021 consultant provided research correlating PTSD with weight gain, including due to medication, and with OSA. 

It was noted the Veteran's weight has progressively increased from service entry when he weighed 170 pounds to separation, weight 205 pounds (BMI 30.3), and to the then current weight of 275 pounds (BMI 40.6). The March 2021 consultant stated the medical literature confirmed a nexus between body weight and weight gain with OSA.

Interestingly, the March 2021 examiner, like the August 2020 examiner, misstated that an adverse side of effect of the Veteran's medication was weight gain, when the examiner concluded the PTSD medication contributed to the Veteran's substantial weight gain.

In addition to the private opinions, the Veteran underwent in-person VA examinations in August 2020 and May 2021 with associated medical opinions, along with July 2022 medical opinions addressing aggravation and the private medical opinions. 

First, the May 2021 VA examiner noted that the August 2020 private examiner incorrectly identified the Veteran's prescribed medication, buspirone, as a benzodiazepine that causes weight gain. Also, the VA examiner stated that by the time the Veteran had been diagnosed with PTSD (201
 like the August 2020 examiner, misstated that an adverse side of effect of the Veteran's medication was weight gain, when the examiner concluded the PTSD medication contributed to the Veteran's substantial weight gain.

In addition to the private opinions, the Veteran underwent in-person VA examinations in August 2020 and May 2021 with associated medical opinions, along with July 2022 medical opinions addressing aggravation and the private medical opinions. 

First, the May 2021 VA examiner noted that the August 2020 private examiner incorrectly identified the Veteran's prescribed medication, buspirone, as a benzodiazepine that causes weight gain. Also, the VA examiner stated that by the time the Veteran had been diagnosed with PTSD (2010), he had already had significant weight gain, and that it was the weight gain not the PTSD that caused the OSA.

Further, the July 2022 VA examiner reviewed the August 2020 and March 2021 private medical opinions. The VA examiner indicated those opinions were methodically and scientifically incorrect in that the private consultants' rationales were based on overall associations and inaccurate assumptions. 

For instance, the assumption the Veteran's weight increased after active duty because of PTSD; however, the VA examiner indicated there were numerous factors in weight gain, including genetic factors, environmental factors, drug abuse, lifestyles, body habitus, sinus conditions, upper respiratory conditions, neurological deficit and/or idiopathic. Of note, neither private consultant addressed these other potential reasons for the Veteran's weight gain.

Also, the July 2022 VA examiner indicated the private examiners' conclusion that because a certain class of psychiatric medications (benzodiazepines) have a side effect for weight gain, therefore those medications caused the Veteran's weight gain was largely an overriding associative based on an assumption. Basically, because it "can" happen does not mean it is applicable to everyone or even the majority of people, including the Veteran. When specifically looking at this Veteran's case, the VA examiner noted he was prescribed psychiatric medications in 2019, and by then he had already experienced decades of obesity.

A medical opinion must support its conclusion with an analysis the Board can consider and weigh against other evidence in the record. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In addition, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). 

It is the Board's responsibility to weigh the conflicting medical evidence to reach a conclusion as to whether service connection may be granted. Id. at 300 (citing Wood v. Derwinski, 1 Vet. App. 190, 193 (1991)). 

Based on the above, the Board places less probative weight on the private consultants' medical opinions and more probative weight on the VA examinations and opinions. As the July 2022 VA examiner noted, the private opinions were generalities with little specificity to this Veteran nor do the private consultants address other possibilities for weight gain and OSA. 

Moreover, and most importantly, the private examiners incorrectly identified the Veteran's prescribed medication, buspirone, as a benzodiazepine that caused weight gain when, according to the VA examiners, it is, in fact, not a benzodiazepine nor does it cause weight gain, which is the core principle of the private opinions establishing a nexus. 

With conclusions based on inaccurate factual assertions, these private consultant opinions have little probative weight. As such, the medical evidence does not support service connection on direct basis or a secondary basis, including with an intermediate step of obesity.

The Board has also considered the Veteran's lay statements that he weighed 205 pounds after leaving service military. Subsequently, VA treatment records indicate his weight increased until he had been diagnosed with PTSD in 2010, and he weighed 254 pounds. When he was diagnosed with OSA in 2020, he weighed 290 pounds and had a BMI of 43.

The Board has considered the Veteran's lay statements that OSA was caused by a service-connected disability (PTSD or obesity associated with his PTSD). While he is competent to report symptoms as this requires only personal knowledge as it comes to him through his senses, he is not competent to offer an opinion as to the etiology of the current disorder due to the medical complexity of the matter involved.

Specifically, the Veteran's statements about weight gain, poor food choices, and eating high calorie foods do not suggest a particular etiology of any such disorder. Such competent evidence concerning the nature and extent of OSA has been provided by the medical personnel who examined him during the current appeal, and who rendered pertinent opinions
 pounds and had a BMI of 43.

The Board has considered the Veteran's lay statements that OSA was caused by a service-connected disability (PTSD or obesity associated with his PTSD). While he is competent to report symptoms as this requires only personal knowledge as it comes to him through his senses, he is not competent to offer an opinion as to the etiology of the current disorder due to the medical complexity of the matter involved.

Specifically, the Veteran's statements about weight gain, poor food choices, and eating high calorie foods do not suggest a particular etiology of any such disorder. Such competent evidence concerning the nature and extent of OSA has been provided by the medical personnel who examined him during the current appeal, and who rendered pertinent opinions in conjunction with the evaluations.

The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disorder is evaluated. The VA examiners explained their reasoning based on an accurate characterization of the evidence. Therefore, the Board attaches greater probative weight to the VA examinations and clinical findings than to the private opinions and lay statements regarding etiology.

In sum, after a careful review of the record, the evidence weighs persuasively against the claim for service connection and there is no doubt to be 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 

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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	B. J. Ferguson, 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.