SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

J.P. NORMAN · 2025 · Case ID: A25027338

DENIED

Summary

The Veteran served from April 1999 to June 2003. He appealed the denial of service connection for obstructive sleep apnea (OSA), asserting it was secondary to his service-connected lumbosacral strain and right knee strain, which he claimed led to obesity and subsequently OSA. The Board acknowledged the Veteran's current OSA diagnosis and his service connection for lumbosacral and right knee strain. However, the Board found the evidence did not establish a nexus between these service-connected conditions and his OSA. The Veteran's lay statements regarding reduced physical activity and weight gain due to his musculoskeletal conditions were found competent and credible but given minimal probative value for establishing the medical nexus. A private medical opinion suggested a link between musculoskeletal pain, sleep disturbances, sedentary lifestyle, weight gain, and OSA, but the Board found it inadequate for failing to address the Veteran's overall obesity etiology, residual physical capacity, and dietary factors. Conversely, a VA examination concluded that obesity is primarily caused by caloric intake rather than physical limitations and that many individuals with orthopedic conditions maintain healthy weights. This VA opinion, deemed competent, credible, and adequately reasoned, was given high probative weight. Weighing the evidence, the Board found the private opinion to be of low probative value and the VA opinion to be of high probative value, persuasively weighing against a nexus. The Board also found no evidence of in-service incurrence of OSA, as the Veteran reported onset in 2019 and no service treatment records mentioned sleep issues. Therefore, direct service connection was also denied. The appeal was denied.

Rationale

No nexus found between service-connected musculoskeletal conditions and OSA.; Private medical opinion found inadequate for failing to address overall obesity etiology.; VA examination found obesity primarily caused by caloric intake, not physical limitations.; No evidence of in-service incurrence of OSA.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240422-436247

Full Decision Text

Citation Nr: A25027338
Decision Date: 03/25/25 Archive Date: 03/25/25

DOCKET NO. 240422-436247
DATE: March 25, 2025

ORDER

Entitlement to service connection for obstructive sleep apnea (OSA) is denied.

FINDING OF FACT

The Veteran's OSA is not secondary to service-connected lumbosacral strain and right knee strain, and it is not otherwise related to an in-service injury or disease.

CONCLUSION OF LAW

The criteria for service connection for OSA-as either (1) due to the Veteran's service or (2) due to the Veteran's lumbosacral strain and right knee strain-have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from April 1999 to June 2003.

In the April 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the November 2023 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

1. Entitlement to service connection for obstructive sleep apnea is denied.

The Veteran asserts that he is entitled to secondary service connection for OSA due to his service-connected conditions of lumbosacral strain and right knee strain causing an intermediary diagnosis of obesity, which in turn caused is OSA diagnosis. The Board finds that the evidence of record persuasively weighs against finding a nexus between the Veteran's service-connected disabilities and his current diagnosis and therefore entitlement to service connection cannot be granted.

Secondary service connection is warranted if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998).

As to the first element of secondary service the AOJ made a favorable finding that the Veteran has a current diagnosis of OSA, and that element is conceded here.

As to the second element of secondary service connection the AOJ similarly made a favorable finding that the Veteran is service connected for lumbosacral strain and right knee strain, and that element is also conceded here.

There still must be a found a nexus between the Veteran's current diagnosis and his service-connected disabilities.

The Veteran provided an April 2023 statement in support of his claim that asserted that due to his musculoskeletal conditions he was unable to exercise, which was the cause of his OSA. In his December 2022 statements in support of his service connection claims for lumbosacral strain and right knee strain the Veteran similarly reported limiting activities such as running, jogging, sports, and yard work due to his musculoskeletal conditions. His statement also reports substantial weight gain in the post-service period. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by the lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's limitation on physical activities and weight gain are matters within his personal knowledge and matters which a lay person is capable of observing and describing. Therefore, the Veteran is found to be competent and credible in his assertion of reduced physical activity due to his musculoskeletal conditions as well as his assertion of weight gain.

However, the fact that the Veteran's reduced physical activities can be determined to be the cause of his obesity diagnosis, and consequently his OSA diagnosis, is a matter which the Veteran is not competent to assert, as it requires medical training to adequately address. No evidence of record supports that the Veteran
observed and described by the lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's limitation on physical activities and weight gain are matters within his personal knowledge and matters which a lay person is capable of observing and describing. Therefore, the Veteran is found to be competent and credible in his assertion of reduced physical activity due to his musculoskeletal conditions as well as his assertion of weight gain.

There are two opinions from competent medical providers which address the issue of the etiology of the Veteran's obesity and consequent OSA diagnoses.

The Veteran submitted an April 2023 opinion from a private medical provider that reached the conclusion that it was as least as likely as not that the Veteran's obesity was due to his service-connected musculoskeletal conditions and that the Veteran's OSA was at least as likely as not the caused by his obesity. The rationale offered to support this conclusion is that musculoskeletal pain is associated with sleep disturbances which in turn have a positive correlation with weight gain according to medical literature. Also, the opinion asserts that musculoskeletal conditions contribute to a sedentary lifestyle which also his correlated with weight gain.

The Board finds the opinion to be inadequate because it does not address the overall etiology of the Veteran's obesity diagnosis. While the opinion draws the conclusion that the Veteran's lack of physical activity and sleep disturbances are at least as likely as not the cause of his obesity diagnosis, it provides no analysis in regard to the Veteran's residual physical capacity or his diet regime and its possible impact on the diagnosis.

While the Veteran has competently asserted that he no longer engages in high impact activities, he does report limited engagement in other physical activities such as yard work and household chores that indicate he is not wholly preempted from any form of exercise. Of note is that the Veteran has maintained employment as a diesel mechanic throughout the post-service period which necessitates at least a moderate amount of physical demand. The residual capacity of the Veteran to engage in some physical exercise is not addressed by the examiner and whether it would impact the Veteran's obesity. Neither does the examiner address whether the Veteran's choice of diet is a contributing factor to his obesity diagnosis. Caloric intake is a major contributing factor to obesity and the opinion is absent for any analysis in regard to its application to the Veteran's etiology for obesity. The opinion as it relates to obesity being a major contributing factor for OSA is found to be reliable, but the intermediary diagnosis of obesity as caused by the Veteran's service-connected disabilities must first be established in order for a nexus to be supported. For these reasons concerning the adequacy of the opinion's analysis, it is found to be of low probative value concerning the nexus between the Veteran's service-connected conditions and his current diagnosis.

The Veteran also attended a VA examination in September 2023. The examiner reviewed the Veteran's available medical records and conducted an in-person examination. The examiner concluded that it was less likely than not that the Veteran's service-connected disabilities were the cause of the Veteran's obesity and therefore the Veteran's OSA. The rationale offered to support this conclusion was that while pain may prevent the Veteran from engaging in some high-impact forms of activity there are multiple other activities and strategies which can be used to manage obesity. The examiner opined that obesity is primarily caused by consuming more calories than the body burns rather than physical activity limitations and among the general population many people with orthopedic conditions maintain a healthy weight. The examiner is deemed to be competent and credible to offer such an opinion and the analysis is found to adequately address the multiple contributing factors to obesity. Accordingly, the opinion is provided high probative weight.

In weighing the evidence of record which supports a nexus between the Veteran's current diagnosis of OSA and service-connected musculoskeletal conditions, the evidence which supports a nexus is found to be of minimal or low probative weight. However, the medical opinion which does not find a nexus is afforded high probative weight. The evidence of record therefore persuasively weighs against finding that a nexus exists between the Veteran's current diagnosis of OSA and his service-connected lumbosacral strain and right knee strain. Without the finding of a nexus a claim for secondary service connection cannot be supported.

Service connection may be granted on a direct basis for a disability resulting from personal injury suffered or disease contracted, or for
provided high probative weight.

Service connection may be granted on a direct basis for a disability resulting from personal injury suffered or disease contracted, or for aggravation of a preexisting injury suffered or disease contracted, in the line of duty in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).

To establish service connection on a direct basis the following elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical "nexus" requirement). Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

As to the first element, as previously stated the Veteran has been found to have a current diagnosis for OSA.

Next, there must be found to be an in-service incurrence of a disease or injury.

The Veteran's service treatment records are silent for any diagnosis, treatment, or complaint for sleep related issues. Nor do any of the statements provided by the Veteran assert in-service onset of the disease and the Veteran noted the onset as 2019 during his September 2023 VA examination.

The evidence of record therefore persuasively weighs against a finding of an in-service incurrence of OSA. Without the finding of an in-service incurrence, a claim for service connection on a direct basis cannot be supported.

For the above reasons, the Board finds that the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for OSA is warranted. Rather, the evidence persuasively weighs against entitlement to service connection. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. 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). The Veteran's appeal is hereby DENIED.

J.P. Norman

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Arner, Jonathan T.

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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