SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

LESLEY A. REIN · 2026 · Case ID: 26000381

DENIED

Summary

The Veteran, a veteran who served from October 1986 to May 1991, including service in Saudi Arabia during the Persian Gulf War, appeals the denial of service connection for obstructive sleep apnea (OSA), claimed as secondary to his service-connected unspecified depressive disorder. The Board found the Veteran qualified as a Persian Gulf War veteran. However, the Board denied service connection for OSA. The Veteran's service treatment records did not indicate any complaints, treatment, or diagnosis of sleep apnea during service. Multiple VA examinations and medical opinions consistently found that the Veteran's OSA was less likely than not related to service, either directly or as secondary to his depressive disorder. Examiners attributed the OSA to post-service weight gain and macroglossia, noting no pathophysiological link between depression and OSA. While the Veteran claimed his OSA was secondary to depression, the medical opinions found no causal connection or aggravation. The Board concluded that the evidence persuasively weighed against service connection, rendering the benefit of the doubt doctrine inapplicable. Therefore, the claim for service connection for obstructive sleep apnea was denied.

Rationale

Service treatment records lack complaints, treatment, or diagnosis of sleep apnea during service.; Multiple VA medical opinions found OSA less likely than not related to service, directly or secondarily to depression.; Examiners cited obesity and macroglossia as primary causes of OSA, with no pathophysiological link to depression.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-59 558

Full Decision Text

Citation Nr: 26000381
Decision Date: 01/12/26 Archive Date: 01/12/26

DOCKET NO. 17-59 558
DATE: January 12, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected unspecified depressive disorder, is denied.

FINDING OF FACT

The most persuasive evidence demonstrates that the Veteran's currently diagnosed obstructive sleep apnea did not have its onset during active duty service and was not otherwise etiologically related to service; nor did the Veteran have an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by obstructive sleep apnea; nor was it due to or aggravated by his service-connected unspecified depressive disorder.

CONCLUSION OF LAW

The criteria for entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected unspecified depressive disorder, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1119, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from October 1986 to May 1991.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this case in April 2022, September 2022, January 2023, September 2023, and July 2024 for further development. The Board is satisfied that there was substantial compliance with the prior remand. See Stegall v. West,?11?Vet. App.?268, 271?(1998);?D'Aries?v. Peake,?22?Vet. App.?97, 105?(2008).

The Veteran testified at a videoconference hearing before the undersigned in November 2021. A transcript is of record.

Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159.

Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).

1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected unspecified depressive disorder, is denied.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Generally, service connection requires: (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 or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166 - 67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d).

As the Veteran served in Saudi Arabia from December 1990 to May 1991, service connection may also be established on a presumptive basis for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, and cannot be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.
498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d).

The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317 (e)(1). The "Southwest Asia theater of operations" refers to Iraq, Kuwait, Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (e)(2). The Persian Gulf War means the period beginning on August 2, 1990, and ending on the date thereafter prescribed by Presidential proclamation or by law. 38 U.S.C. § 101 (33); 38 C.F.R. § 3.2 (i). On that basis, the Board finds that the Veteran qualifies as a Persian Gulf War veteran within the meaning of the applicable statute and regulation.

A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317 (a)(2)(i).

For purposes of this presumption, the term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered "medically unexplained." 38 C.F.R. § 3.317 (a)(2)(ii).

For purposes of this presumption, the term "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3).

Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period are considered chronic. The six-month period of chronicity is measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4).

Signs or symptoms that may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b).

In the case of claims based on an undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8 9 (2004). Further, lay persons are considered competent to report objective signs of illness. Id.

Compensation shall not be paid under
11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b).

Compensation shall not be paid under 38 C.F.R. § 3.317 for a chronic disability: (1) if there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or (2) if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or (3) if there is affirmative evidence that the disability is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317 (a)(7).

Notwithstanding the provisions relating to presumptive service connection, a veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994).

In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995).

Service treatment records do not show complaints of, treatment for, or a diagnosis of sleep apnea or a sleep disorder.

At the November 2021 hearing, the Veteran asserted that his obstructive sleep apnea was secondary to his service-connected depressive disorder.

In a May 2022 VA examination, the Veteran was diagnosed with obstructive sleep apnea. The examiner opined that it was less likely than not due to her active duty service, due to her service-connected unspecified depressive disorder, or aggravated by her service-connected unspecified depressive disorder. The examiner found that service treatment records did not show symptoms or diagnosis of obstructive sleep apnea. The Veteran was diagnosed with obstructive sleep apnea 25 years after separation from service with AHI of 15 (very low). As such, the examiner found that it was unlikely that the Veteran had sleep apnea appeared in service or was somehow etiologically related to service.

The examiner also stated that obstructive sleep apnea was a condition that caused periods of stopped breathing during sleep due to mechanical obstruction of the upper airway. These pauses in breathing usually lasted 10 seconds or longer and breathing usually resumed with a loud gasp, snort, or body jerk. Disturbances of sleep in general, such as insomnia, dream problems, etc. were frequently associated with depression as symptoms of the condition. However, this was not the same as sleep apnea, which was a separate medical condition. Therefore, it was less likely than not that the Veteran's sleep apnea was secondary to his depression or other mental health condition. Further, there was no evidence of aggravation of his sleep apnea in available medical records which showed natural progression of this condition.

In a November 2022 VA medical opinion, the examiner noted that a February 2017 sleep study showed evidence of mild to moderate positional and REM related sleep apnea. The Veteran also had moderate macroglossia and one of the common causes of macroglossia included smoking. The examiner opined that the Veteran's obstructive sleep apnea was not caused by his service-connected unspecified depressive disorder. There was no pathophysiologic mechanism by which depressive disorder caused obstruction of the oropharynx by the base of the tongue (the proximate cause of obstructive sleep apnea). The examiner also opined that the Veteran's obstructive sleep apnea was not aggravated by his service-connect unspecified depressive disorder. There was no causal connection between the two disorders.

The examiner opined that the Veteran's obstructive sleep apnea did not have its onset during active duty service and was
The Veteran also had moderate macroglossia and one of the common causes of macroglossia included smoking. The examiner opined that the Veteran's obstructive sleep apnea was not caused by his service-connected unspecified depressive disorder. There was no pathophysiologic mechanism by which depressive disorder caused obstruction of the oropharynx by the base of the tongue (the proximate cause of obstructive sleep apnea). The examiner also opined that the Veteran's obstructive sleep apnea was not aggravated by his service-connect unspecified depressive disorder. There was no causal connection between the two disorders.

The examiner opined that the Veteran's obstructive sleep apnea did not have its onset during active duty service and was not otherwise etiologically related to service. He stated that review of the records showed no evidence of obstructive sleep disorder during service. Given the known risk factors, he attributed the Veteran's current obstructive sleep apnea to weight gain since leaving service (to a BMI more associated with obstructive sleep apnea) and possibly macroglossia from smoking (which develops over many years).

In a February 2023 VA examination, the Veteran was diagnosed with obstructive sleep apnea. The examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was due to his service. The examiner stated that although the Veteran may have had sleep issues in service, given that that his sleep apnea was not diagnosed until after service, he was unable to attribute the Veteran's in-service sleep issues to his current sleep apnea diagnosis. Sleep issues were a wide variety of considerations with sleep apnea just being one.

The examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was due to his service-connected depressive disorder. While there was an associative relationship between psychiatric disorders and obstructive sleep apnea, according to current literature, a causative relationship did not exist. As for aggravation, the examiner stated that given there was no causation, there could be no aggravation by definition.

In a June 2023 VA memorandum, the Veteran participated in a TERA based on his service in Southwest Asia.

In a July 2023 VA medical opinion, the examiner opined that the Veteran's obstructive sleep apnea was less likely than not caused by the indicated toxic exposure risk activity(ies) (TERA), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all the Veteran's TERA. The Veteran served in the Gulf War and was exposed to risk activity, including oil wells. However, there was no causal association between the documented exposures and his obstructive sleep apnea.

In an October 2023 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was due to his service-connected depressive disorder. The examiner noted that the Veteran was not diagnosed with obstructive sleep apnea until a February 2017 sleep study, over 24 years after service and his service-connected unspecified depressive disorder. Just prior to this sleep study in November 2017, the Veteran had a BMI of 30.1, placing him in the class 1 obesity category. In adults, the most common cause of obstructive sleep apnea was excess weight and obesity, which were associated with excess soft tissue of the mouth and throat. Weight gain could cause fat to accumulate in the neck area. While there was some correlation between sleep disorders and depression, it appears that it was generally felt that sleep disorders could cause depression, not that depression caused sleep disorders. Further, when a sleep issue was associated with depression, it was most commonly insomnia, not obstructive sleep apnea.

The examiner further opined that it was less likely than not that the Veteran's obstructive sleep apnea was aggravated beyond its natural progression by his service-connected depressive disorder. The examiner found that the baseline level of severity of sleep apnea was AHI 15, the lowest end of the range for moderate obstructive sleep apnea, as shown in the February 2017 sleep study. The current severity of the Veteran's sleep apnea was not greater than the baseline. If the Veteran's sleep apnea were aggravated beyond its natural progression, severe sleep apnea would be anticipated. Moreover, per the February 2023 VA examination, the course of the Veteran's condition had stayed the same and there was no functional impact. If his sleep apnea was aggravated beyond its natural progression, it would be anticipated that some of the aforementioned parameters would be remarkable.

In an October 2024 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was due to his TERA after considering the
, as shown in the February 2017 sleep study. The current severity of the Veteran's sleep apnea was not greater than the baseline. If the Veteran's sleep apnea were aggravated beyond its natural progression, severe sleep apnea would be anticipated. Moreover, per the February 2023 VA examination, the course of the Veteran's condition had stayed the same and there was no functional impact. If his sleep apnea was aggravated beyond its natural progression, it would be anticipated that some of the aforementioned parameters would be remarkable.

In an October 2024 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was due to his TERA after considering the total potential exposure through all applicable military deployments and the synergistic combined effect of all TERA. The examiner noted that the Veteran participated in a TERA due to his service in Southwest Asia from 1990 to 1991. As such, he was presumed to be exposed to burn pits and oil well fires, including benzene, ethyl benzene, m-xylene, and naphthalene, as documented in ILER. No one of these compounds, in isolation or synergism, had been associated with development of obstructive sleep apnea. They could cause lung problems and reactive airway disease, but these were pathologies completely different than obstructive sleep apnea, where the mechanism causing this was the mechanical obstruction of upper airways. The main cause of obstructive sleep apnea was obesity and the Veteran was obese. He was also found to have moderate macroglossia, which was not related to any of the environmental toxins that he was presumptively exposed to and also likely contributed etiologically with the obstruction of upper airways and obstructive sleep apnea.

According to post-service VA treatment records, the Veteran was first diagnosed with obstructive sleep apnea in a February 2017 sleep study. He had earlier undergone a sleep study in December 2007, but he was diagnosed with loud snoring with no evidence for significant obstructive sleep apnea. In April 2023, it was noted that a January 2023 sleep test showed mild obstructive sleep apnea and snoring. The medical provider discussed the impact of weight on sleep disordered breathing and overall health. The medical records also showed that the Veteran had a history of smoking and that he smoked at least up to August 2023, which noted that he smoked three to four cigars a day.

Based on a careful review of the subjective and clinical evidence, the Board finds that the evidence persuasively weighs against finding that service connection is warranted for the Veteran's obstructive sleep apnea.

As an initial matter, the Board finds that the Veteran's obstructive sleep apnea is not an undiagnosed illness as it has a diagnosis and it is not a medically unexplained chronic multisymptom illness because both the etiology and pathophysiology of the condition are at least partially understood.

The February 2017 sleep study diagnosed the Veteran with obstructive sleep apnea, which has been confirmed by the VA examiners. As the Veteran's obstructive sleep apnea is a diagnosed condition, it cannot be considered an undiagnosed illness, but it is eligible for consideration as a medically unexplained chronic multisymptom illness. 38 C.F.R. § 3.317 (a)(1)(ii), (a)(2)(ii).

The November 2022, October 2023, and October 2024 VA medical opinions indicate that the etiology of the Veteran's obstructive sleep apnea includes his obesity and macroglossia (caused by his smoking) and that the pathophysiology of his obstructive sleep apnea includes mechanical obstruction of upper airways. As such the examiners have indicated that the Veteran's obstructive sleep apnea has, at least, a partially understood etiology and pathophysiology.

The Board acknowledges that the May 2022 VA examination opinions were found inadequate in its September 2022 decision, the November 2022 VA medical opinion as to secondary aggravation was found inadequate in its January 2023 decision, the February 2023 VA medical opinion as to secondary aggravation was found inadequate in its September 2023 decision, and the July 2023 VA medical opinion (TERA) was found inadequate in its July 2024 decision.

The Board notes that service treatment records do not show complaints of, treatment for, or a diagnosis of sleep apnea or sleep disorders. The Board finds that the November 2022 VA medical opinion as to whether the Veteran's obstructive sleep apnea was due to service (on a direct basis), October 2023 VA medical opinion addressing whether the Veteran's obstructive sleep apnea was secondary to his service-connected depressive disorder, and October 2024 VA medical opinions are adequate as indicated and persuasive as to the etiology of the Veteran's obstructive sleep apnea. The examiners based their opinions on physical examination, a review of the medical records, and medical research. Significantly, these opinions are supported by fully articulated rationales. Prejean v. West, 13 Vet. App. 444 (2000); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Additionally, these opinions are corroborated by contemporaneous medical records. As such, the Board finds that the persuasive evidence of record shows that the Veteran's obstructive sleep apnea did not have its onset during service, was otherwise etiologically related to service, include TERA, or secondary to his service-connected depressive disorder.

The Board acknowledges that the Veteran is competent to describe observable symptoms of his sleep apnea, but he is not competent to opine as to the etiology of the disability, as he is not shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the lay opinions that the Veteran's obstructive sleep apnea had its onset during service, was otherwise etiologically related to service, or secondary to his depressive disorder does not constitute competent medical evidence and lacks probative value.

For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for obstructive sleep apnea is warranted. Rather, the evidence persuasively weighs against finding in favor of the Veteran's service connection claim. The benefit of the doubt doctrine, see 38 U.S.C. § 5107 (b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

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Accordingly, the claim for service connection for obstructive sleep apnea, to include as secondary to service-connected unspecified depressive disorder, is denied.

LESLEY A. REIN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Ko, Elise

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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