SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

A. ISHIZAWAR · 2025 · Case ID: 25005229

DENIED

Summary

The veteran served from April 1980 to August 1991. The veteran appeals the denial of service connection for sleep apnea and a heart disorder. The Board previously denied these claims, but the Court of Appeals for Veterans Claims remanded them for further adjudication. The primary issue for sleep apnea was whether it was related to service or secondary to the service-connected right knee disorder via obesity. The Board found that the veteran's diagnosis of central sleep apnea, as supported by multiple VA examinations and private records, was not related to service or aggravated by the knee condition or obesity. The Board gave significant weight to VA examiner opinions that found no nexus, noting the veteran's own testimony that he had no sleep problems during service and that his heart condition predated his weight gain. For the heart disorder, the Board found competent evidence of current diagnoses (CAD, cardiomyopathy, myocardial infarction) but no in-service complaints, findings, or treatment. VA examinations consistently rendered negative nexus opinions, stating the heart condition predated the weight gain and was unrelated to the knee disorder. The Board found the VA opinions probative and the evidence weighed against a service connection for both sleep apnea and the heart disorder. Service connection for both conditions was denied.

Rationale

Service treatment records do not document sleep apnea.; Postservice records show diagnosis in October 2013, years after service.; VA examiners provided negative nexus opinions, stating no relationship to service or knee disorder/obesity.; Veteran's testimony indicated no sleep problems during service.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

15-04 238

Full Decision Text

Citation Nr: 25005229
Decision Date: 04/17/25 Archive Date: 04/17/25

DOCKET NO. 15-04 238
DATE: April 17, 2025

ORDER

Service connection for sleep apnea is denied.

Service connection for a heart disorder is denied.

FINDINGS OF FACT

1. The evidence persuasively weighs against a finding that the Veteran's sleep apnea had its onset in or is related to his active duty service or is due to or aggravated by his service-connected right knee disorder, to include any associated obesity.

2. The evidence persuasively weighs against a finding that the Veteran's heart disorder had its onset in or is related to his active duty service or is due to or aggravated by his service-connected right knee disorder, to include any associated obesity.

CONCLUSIONS OF LAW

1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310

2. The criteria for service connection for a heart disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from April 1980 to August 1991.

In July 2018, the Veteran was provided a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record.

In a decision issued in July 2022, the Board, in pertinent part, denied service connection for sleep apnea and a heart disorder. The Veteran appealed these decisions to the United States Court of Appeals for Veterans Claims (Court). In June 2023, the Court issued an Order that vacated the Board's July 2022 decision with respect to the claims noted above and remanded these matters for adjudication consistent with the instructions outlined in a July 2023 Joint Motion for Partial Remand (JMPR).

In November 2024, the Board most recently remanded the current claims for additional development.

In the July 2023 JMPR, the Parties agreed that the Board did not address a March 2010 VA sleep medicine record noting a diagnosis of obstructive sleep apnea or an October 2013 VA sleep study report noting an impression of severe central more than obstructive sleep apnea. The Board emphasizes, however, that a thorough review of the record reveals that the March 2010 VA sleep medicine record does not exist. In fact, the record reflects that the Veteran initiated treatment with VA in October 2010. Therefore, he could not have undergone a VA sleep study in March 2010. Private treatment records were also reviewed and while they included reports from studies done in October 2013 and June 2014, there was no report available from March 2010. Further, as will be explained more fully below, the Board sought clarification regarding the Veteran's sleep apnea diagnosis, and it is determined that the Veteran has central sleep apnea rather than obstructive sleep apnea. Consequently, the Board has largely adopted its prior decision regarding service connection for sleep apnea.

The Parties also agreed that the Board failed to address whether the October 2020 VA medical opinion was adequate in light of the fact that it did not address whether the Veteran's knee disability aggravated his obesity. Consistent with the JMPR, the Board obtained a new December 2024 VA medical opinion to address whether the Veteran's right knee disability aggravated his obesity. As this evidence does not change the Board's determination, the Board will largely adopt its previous determination.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §3.303(d). There are three requirements to establish service connection: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Service
.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §3.303(d). There are three requirements to establish service connection: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Service connection may also be established on a secondary basis for a disability that is due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).

The Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465, 469 (1994).

1. Entitlement to service connection for sleep apnea

As an initial matter, the Board notes that the Veteran's VA treatment records provide conflicting evidence regarding the Veteran's diagnosis for sleep apnea. In that regard, in October 2013, the Veteran was diagnosed with central, more than obstructive sleep apnea. Further, the Veteran's other VA treatment records indicate diagnoses for central and obstructive sleep apnea. See, e.g., June 2014, December 2016, February 2017, March 2018, July 2019, and March 2020 VA Treatment records. As a result, the Board sought clarification as to whether the Veteran had obstructive versus central sleep apnea.

In December 2024, the Regional Office (RO) obtained a VA medical opinion from an appropriate examiner to address the Veteran's sleep apnea diagnosis. After a review of the Veteran's claims file, the examiner explained that, while there were multiple instances in the Veteran's medical records where obstructive sleep apnea was documented, the Veteran's October 2013 medical sleep medicine polysomnogram and June 2014 sleep study showed a diagnosis for central sleep apnea. The examiner explained that these tests were the standard for diagnosis and, therefore, central sleep apnea was the accurate diagnosis, not obstructive sleep apnea. The Board assigns this medical opinion significant probative value, as the VA examiner's opinion is consistent with the Veteran's VA and private treatment records and is based on her knowledge and skill as a medical provider.

Based on the foregoing, the Board finds that the most probative evidence of record establishes that the Veteran has a diagnosis of central sleep apnea, rather than obstructive sleep apnea. Accordingly, the Veteran that meets the first element for establishing service connection for sleep apnea on a direct and secondary basis.

While the Veteran has a current diagnosis for central sleep apnea, the Veteran's service treatment records (STRs) do not document complaints, findings, or treatment for any sleep apnea disorder. Moreover, postservice treatment records only show diagnosis and treatment for sleep apnea as early as October 2013 and do not include any opinions concerning the etiologic relationship of that disability to the Veteran's service. Neither the Veteran nor his representative has offered any specific contention as to how they believe the Veteran's sleep apnea is directly related to his active duty service.

Thus, while there is competent medical evidence of a current disability, there is no indication in the record that the Veteran's sleep apnea had its onset in or was caused/aggravated by service. The Veteran was provided a VA examination in October 2019 and the VA examiner diagnosed the Veteran with central sleep apnea and rendered a negative nexus opinion, explaining that there was no objective evidence in the service treatment records or discharge medical records for any sleep disturbance. Similarly, in December 2024 a different VA examiner provided another negative nexus opinion, explaining that the Veteran was not diagnosed with central sleep apnea until October 2013, many years after separation from active duty. The examiner also noted the Veteran's testimony that he did not have sleep problems during active duty service. The Board finds these opinions to be probative as they are based on a thorough review of the Veteran's claims file and are supported by the Veteran's own testimony. There are also no medical opinions to the contrary. Accordingly, the weight of the evidence is against finding that a medical nexus exists between the Veteran's sleep apnea and his military service and entitlement to service connection for sleep apnea on a direct basis is denied.

Notably, it is the Veteran's primary contention that his sleep apnea is related to his service-connected right knee disorder, by way of associated obesity. In fact, at the July 2018 Board hearing, the Veteran indicated he was only relating his sleep apnea to his weight gain. Therefore, the principal question for the Board is whether there is a nexus between the Veteran's sleep apnea and his service-connected right knee disorder, by way of his obesity/weight gain.

The question of whether his sleep apnea is etiologically related to his right knee disorder was initially addressed in the October 2019 VA medical opinion. The VA examiner reviewed the claims file and opined that the Veteran's sleep apnea was less likely than not caused by or due to his right knee disorder. The examiner explained that the Veteran's diagnosis for central sleep apnea was a separate entity entirely from his service-connected right knee disorder and medical literature did not support a medical relationship. The examiner explained further that central sleep apnea was a medical condition that was characterized by a lack of drive to breathe during sleep resulting in repetitive periods of insufficient ventilation and compromised gas exchange and there was no medical evidence in the literature that any knee condition or diagnosis had any connection to or aggravation of a diagnosis of central sleep apnea.

In August and October 2020, clarification was sought regarding whether the Veteran's sleep apnea was etiologically related to the right knee disorder, by way of any associated obesity. The August 2020 VA examiner rendered a negative nexus opinion and indicated that obstructive sleep apnea was characterized as a structural upper airway obstruction with risk factors of obesity, gender, age and upper airway crowding such as enlarged tonsils. The examiner explained, however, that central sleep apnea occurred because the brain did not send proper signals to the muscles that controlled breathing which was different from obstructive sleep apnea and unrelated to obesity or to the right knee condition. The October 2020 VA examiner similarly rendered a negative nexus opinion and indicated that the Veteran's knee condition did not cause him to be obese, as obesity occurred due to increased caloric intake and decreased expenditure. The examiner stated the Veteran's knee condition did not preclude him from all forms of exercise and did not cause him to increase his caloric intake; therefore, it did not cause his obesity. Moreover, the examiner noted that while obesity was a risk factor for sleep apnea, thin people could also have sleep apnea. Therefore, it would be resorting to mere speculation to opine that the Veteran had sleep apnea because of his weight gain and would not have had it otherwise.

The Board assigns the above medical opinions significant probative value, as the VA examiners based their opinion on their knowledge and skill as medical providers and a thorough review of the Veteran's claims file. There is no competent evidence to the contrary.

The Board acknowledges the Veteran's general contention that his sleep apnea is related to his service-connected right knee disorder, to include his obesity/weight gain. However, he is not competent to provide such a nexus opinion, as such issue is medically complex and requires knowledge of the interaction between multiple organ systems in the body. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As indicated above, the Veteran has been diagnosed with central sleep apnea, and not obstructive sleep apnea. Such diagnosis has competently been determined to be associated with the failure of the brain to send proper signals and not obesity. Consequently, the Board gives more probative weight to the October 2019 and August and October 2020 VA examiners' negative nexus opinions.

Based on the foregoing, the Board concludes that the evidence weighs persuasively against the Veteran's secondary service connection claim for sleep apnea. As outlined, the record does not support a causal nexus between the Veteran's sleep apnea and his service-connected right knee disorder, to include any associated obesity. The October 2019 and August and October 2020 VA examiners adequately found that the Veteran's sleep apnea was not related to or aggravated by his service-connected right knee disorder/obesity. As indicated, central sleep apnea occurs because the brain did not send proper signals to the muscles that controlled breathing which is unrelated to obesity or a right knee condition. There is no competent contrary evidence, to include any medical opinions, of record. As such, entitlement to service connection for sleep apnea, to include as secondary to service-connected right knee disorder, is denied.

1. Entitlement to service connection for a heart disorder.

The record establishes that the Veteran has diagnoses for heart disorders, to include coronary artery disease (CAD), cardiomyopathy, and old myocardial infarction. See October 2019 VA Examination report. Such evidence is sufficient to meet element (1) for establishing service connection on a direct and secondary basis.

The Board notes, however, that the Veteran's STRs do not document complaints, findings, or treatment for any heart disorder. The Board acknowledges that the Veteran underwent a routine electrocardiogram (ECG) on July 11, 1991 in conjunction with his separation examination. The Veteran was noted to have sinus bradycardia with marked sinus arrhythmia. In spite of this finding, the ECG was noted to be normal. This was reiterated in the July 11, 1991 separation examination report that noted that the Veteran's heart was clinically normal. Notably, the Veteran testified that he did not receive any treatment for his heart during service. See July 2018 Board Hearing Transcript. Moreover, postservice treatment records only show diagnosis and treatment for heart problems beginning in 2011 after the Veteran experienced chest pain and was treated for a myocardial infarction and diagnosed CAD and cardiomyopathy. These records do not include any opinions concerning the etiologic relationship of that disability to the Veteran's service. Neither the Veteran nor his representative has offered any specific contentions as to how they believe the Veteran's heart disorder is directly related to his active duty service.

Thus, while there is competent medical evidence of a current disability, there is no indication in the record that the Veteran's heart disorder had its onset in or was caused/aggravated by service. The Veteran was provided a VA examination in October 2019 and the examiner documented the Veteran's reports that his history for chest pain began in February 2011 when he presented to the ER and was diagnosed with a myocardial infarction. The examiner diagnosed multiple heart disorders, to include CAD, cardiomyopathy, and old myocardial infarction, and rendered a negative nexus opinion. The examiner explained that, at the time of separation, the Veteran denied any cardiac symptoms and, although an ECG noted Sinus Bradycardia with Sinus Arrhythmia, these findings were considered normal for healthy, young individuals. The examiner noted that, by the Veteran's own admission, he was not diagnosed with CAD until 2011, and he had no known prior cardiac history. Therefore, a nexus was not established.

Similarly, in December 2024 a different VA examiner provided another negative nexus opinion, explaining that the Veteran's STRs did not support that the
examiner diagnosed multiple heart disorders, to include CAD, cardiomyopathy, and old myocardial infarction, and rendered a negative nexus opinion. The examiner explained that, at the time of separation, the Veteran denied any cardiac symptoms and, although an ECG noted Sinus Bradycardia with Sinus Arrhythmia, these findings were considered normal for healthy, young individuals. The examiner noted that, by the Veteran's own admission, he was not diagnosed with CAD until 2011, and he had no known prior cardiac history. Therefore, a nexus was not established.

Similarly, in December 2024 a different VA examiner provided another negative nexus opinion, explaining that the Veteran's STRs did not support that the Veteran was diagnosed or treated for a heart condition during service. The examiner's opinion also appears to have been based on the Veteran's hearing testimony that he did not receive any treatment for his heart during service.

The Board finds the above opinions to be probative as they are based on review of the Veteran's claims file and are adequately supported. There are also no medical opinions to the contrary. Accordingly, the weight of the evidence is against finding that a medical nexus exists between the Veteran's heart disorder and his military service and entitlement to service connection for a heart disorder on a direct basis is denied.

Notably, it is the Veteran's primary contention that his heart disorder is related to his service-connected right knee disorder, by way of associated obesity. In fact, at the July 2018 Board hearing, the Veteran indicated he was only relating his heart disorder to his weight gain. Therefore, the principal question for the Board is whether there is a nexus between the Veteran's heart disorder and his service-connected right knee disorder, by way of his obesity/weight gain.

The question of whether his heart disorder is etiologically related to his right knee disorder was addressed initially in an October 2019 VA medical opinion. The VA examiner reviewed the claims file and opined that the Veteran's heart disorder was less likely than not caused by or due to his right knee disorder. The examiner explained that the Veteran's heart disorders were separate entities entirely from the service-connected right knee disorder and aggravation was not possible or plausible beyond natural progression of the heart disorder. The examiner also indicated that there was no direct causality of obesity and CAD, because CAD was multifactorial in nature and not a direct result of obesity.

In October 2020, further clarification was sought regarding whether the heart disorder was etiologically related to the Veteran's right knee disorder, by way of any associated obesity. The VA examiner rendered a negative opinion and explained that the Veteran's right knee disorder did not cause him to become obese because obesity was caused by an increase in caloric intake and a decrease of caloric expenditure, and the knee condition did not preclude him from all forms of exercise and did not cause him to increase his caloric intake. The examiner reiterated that the Veteran's CAD and right knee disorder were not medically related because CAD was a separate entity entirely from his right knee disorder and unrelated to it.

In the July 2023 JMPR, the Parties agreed that the Board erred when it failed to address the adequacy of the October 2020 VA medical opinion, because the examiner failed to address whether the Veteran's knee disability aggravated his obesity.

Consistent with the July 2023 JMPR, the Board remanded this claim for a new VA medical opinion to specifically determine whether the Veteran's right knee disability had aggravated his obesity. In December 2024, the RO obtained a VA medical opinion to address this question. The VA examiner opined that the Veteran's heart disorder was less likely than not caused or aggravated by his right knee disorder. The examiner explained that a review of the medical literature confirmed that the pathophysiology of the knee was not related to disorders of the heart. The examiner acknowledged the Veteran's reports that he gained 80 pounds from not being able to exercise or work. The examiner explained, however, that weight gain is caused by consuming more calories than the body uses for energy each day which is the primary cause of weight gain and, although movement may be more difficult with the right knee disorder, it was not the primary cause for the reported weight gain. The examiner also opined that it was at least as likely as not that weight gain was aggravated by the right knee condition. However, the examiner concluded that it was less likely than not that weight gain due to the right knee was a substantial factor in causing the heart disorder. The examiner explained that the Veteran reported weight gain in 2013 and his heart condition began in 2011, which predated the weight gain aggravated by the knee condition.

The Board assigns the above medical opinions significant probative value, as the VA examiners based their
energy each day which is the primary cause of weight gain and, although movement may be more difficult with the right knee disorder, it was not the primary cause for the reported weight gain. The examiner also opined that it was at least as likely as not that weight gain was aggravated by the right knee condition. However, the examiner concluded that it was less likely than not that weight gain due to the right knee was a substantial factor in causing the heart disorder. The examiner explained that the Veteran reported weight gain in 2013 and his heart condition began in 2011, which predated the weight gain aggravated by the knee condition.

The Board acknowledges the Veteran's testimony that he gained weight as a result of his inability to exercise/work due to his right knee disorder and that his heart disorder was related to the obesity/weight gain. However, he is not competent to provide such a nexus opinion, as such issue is medically complex and requires knowledge of the interaction between multiple organ systems in the body. See Jandreau, 492 F.3d at 1377 n.4. Furthermore, as indicated above, the VA examiners have competently determined that the Veteran's right knee disorder is a separate entity entirely from his heart disorder and has no relationship to it. The December 2024 VA examiner has also competently determined that the Veteran's obesity that became aggravated by his right knee disorder was not a substantial factor in causing the Veteran's heart disorder, as the Veteran's heart disorder occurred prior to him gaining weight. Consequently, the Board gives more probative weight to the October 2019, October 2020, and December 2024 VA examiners' negative nexus opinions.

Based on the foregoing, the Board concludes that the evidence weighs persuasively against the Veteran's secondary service connection claim for a heart disorder. As outlined, the record does not support a causal nexus between the Veteran's heart disorder and his service-connected right knee disorder, to include any associated obesity. The October 2019, October 2020, and December 2024 VA examiners adequately found that the Veteran's heart disorder was not related to or aggravated by his service-connected right knee disorder, to include by way of obesity. There is no competent contrary evidence, to include any medical opinions, of record. As such, entitlement to service connection for a heart disorder, to include as secondary to service-connected right knee disorder, is denied.

A. ISHIZAWAR

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Metzner, Paul

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.

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