SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

L. B. CRYAN · 2026 · Case ID: A26001133

DENIED

Summary

The veteran, who served from August 1971 to September 2001, including service in the Gulf War theater of operations, appeals the denial of service connection for obstructive sleep apnea. The claim was also asserted as secondary to his service-connected hypertension and degenerative changes of the lumbar spine. A March 2013 sleep study confirmed a diagnosis of obstructive sleep apnea, with risk factors including obesity and a large neck size. However, service treatment records were negative for sleep apnea or related symptoms, and the veteran affirmatively denied sleep-related issues in multiple post-service medical history reports. VA examinations in July 2019 and April 2024 were initially unable to locate the sleep study, but a subsequent August 2024 examination confirmed the diagnosis. The July 2019 and April 2024 examiners opined that the sleep apnea was less likely than not related to service or secondary to hypertension, citing obesity as the primary risk factor and a lack of medical evidence linking hypertension to sleep apnea. The August 2024 examiner also concluded less likely than not nexus to service or TERA, and less likely than not secondary to hypertension, noting obesity outweighed TERA and that hypertension and sleep apnea are not medically related. The Board found the evidence persuasively weighed against service connection, and the benefit of the doubt doctrine was inapplicable. Service connection for obstructive sleep apnea was denied.

Rationale

Service treatment records negative for sleep apnea or related symptoms.; Veteran denied sleep issues in multiple post-service reports.; VA examinations found less likely than not nexus to service, TERA, or hypertension.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250223-521193

Full Decision Text

Citation Nr: A26001133
Decision Date: 01/06/26 Archive Date: 01/06/26

DOCKET NO. 250223-521193
DATE: January 6, 2026

ORDER

Service connection for obstructive sleep apnea, to include as secondary to the service-connected hypertension and/or degenerative changes of the lumbar spine, is denied.

FINDING OF FACT

The Veteran's obstructive sleep apnea was not incurred in and is not related to service; and was not caused or aggravated by the service-connected hypertension and/or degenerative changes of the lumbar spine.

CONCLUSION OF LAW

The criteria for service connection for obstructive sleep apnea, to include as secondary to the service-connected hypertension and/or degenerative changes of the lumbar spine, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.103, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from August 1971 to September 2001.

This case is before the Board of Veterans' Appeals (Board) on appeal from a December 10, 2024, Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that decision, the RO readjudicated the previously denied claim for service connection for obstructive sleep apnea based on receipt of new and relevant evidence, but denied the claim on the merits.

On February 23, 2025, VA received the Veteran's VA Form 10182 Decision Review Request: Board Appeal (Notice of Disagreement (NOD)). The Veteran selected the Direct Review docket.

Therefore, the Board will decide the appeal "based on the evidence of record at the time of the prior decision." 38 C.F.R. § 20.301.

Given that the RO readjudicated the claim for service connection for obstructive sleep apnea based on receipt of new and relevant evidence and readjudication was not clearly erroneous, the Board is bound by this favorable finding. 38 C.F.R. § 3.104(c).

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider regarding claim(s) that have been denied by this decision in whole or in part, he 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[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Entitlement to service connection for obstructive sleep apnea, to include as secondary to the service-connected hypertension and/or degenerative changes of the lumbar spine.

Prior to the rating decision on appeal, the Veteran contended that his obstructive sleep apnea is caused or aggravated by his service-connected hypertension. In his February 23, 2025, NOD, he also asserted that his obstructive sleep apnea is caused or aggravated by his service-connected degenerative changes of the lumbar spine.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38?U.S.C. §§?1110, 1131, 5107;?38?C.F.R. §?3.303. The three-element test for service connection requires evidence of: (1)?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 in-service disease or injury. Shedden?v.?Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.310(d).

Service connection for a claimed disability may be established?on a?secondary?basis if?that?disability that is due to or the result of a service-connected disease or injury.? 38?C.F.R. §?3.310(a).? Establishing service connection as secondary to a service-connected disability requires a current disability that was either caused or aggravated by a service-connected disability.? 38?C.F.R. §?3.310(a). In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. See Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding that a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

At the outset, a March 2013 sleep study confirmed a diagnosis of obstructive sleep apnea. At the time of the study, the Veteran had a body mass index (BMI) of 32.0 and neck size of 18 inches.

However, July 2019 and April 2024 VA examiners for sleep apnea were apparently unable to locate this study, and suggested that the Veteran did not have an obstructive sleep apnea diagnosis. A subsequent August 2024 VA examination for sleep apnea (based on a records review rather than an in-person examination) acknowledged the March 2013 sleep study and confirmed the Veteran's obstructive sleep apnea diagnosis.

During the July 2019 examination, the Veteran reported "a history of snoring and waking up six or seven times a night." The August 2024 examination indicates that the Veteran underwent a sleep study in March 2013 due to "a reported history of snoring, waking up throughout the night, daytime fatigue, and obesity." The Veteran has not indicated when his snoring and nighttime awakenings began.

However, service treatment records (STRs) are wholly negative for evidence of a diagnosis of obstructive sleep apnea or sleep-related symptoms. Notably, the Veteran affirmatively denied frequent trouble sleeping in Reports of Medical History dated February 1, 1972, November 5, 1981, June 15, 1982, June 15, 1983, July 10, 1984, September 15, 1988, May 17, 1994, and May 8, 2001. At the time of separation, he was noted to have a "medium," rather than "obese" build

Nonetheless, service personnel records reflect that the Veteran had service in the Gulf War theater of operations between August 2, 1990, and July 31, 1991. Therefore, as noted in a June 2, 2023, memorandum in this regard, he is conceded to have participated in a toxic exposure risk activity (TERA) during service.

Despite finding that the Veteran did not have a diagnosis of obstructive sleep apnea, the July 2019 examiner opined that the obstructive sleep apnea was less likely than not incurred in or caused by service. The examiner noted the Veteran's statements regarding diagnosis of sleep apnea "5-6" years ago, or "at least 13 years after separation from service."

Similarly, the April 2024 examiner found that the Veteran's obstructive sleep apnea was less likely than not "secondary" to the service-connected hypertension. The examiner noted that there was "no scientific or objective evidence that hypertension is a risk factor for sleep apnea." Furthermore, the examiner identified other risk factors for sleep apnea, including older age, male sex, obesity, and craniofacial and upper airway abnormalities.

Finally, the August 2024 examiner provided opinions regarding direct nexus to service, to include as due to the in-service TERA, and secondary nexus to the service-connected hypertension.

First, regarding non-TERA direct nexus, the examiner concluded that the obstructive sleep apnea was less likely than not incurred in or caused by an in-service injury, event, or disease.' The examiner noted that there was no objective evidence of obstructive sleep apnea during active duty and that the Veteran was not diagnosed with obstructive sleep apnea until 2013.

Next, regarding nexus to the Veteran's in-service TERA, the examiner concluded that it was less likely than not that the obstructive sleep apnea was caused by the in-service
.

Finally, the August 2024 examiner provided opinions regarding direct nexus to service, to include as due to the in-service TERA, and secondary nexus to the service-connected hypertension.

Next, regarding nexus to the Veteran's in-service TERA, the examiner concluded that it was less likely than not that the obstructive sleep apnea was caused by the in-service TERA. The examiner noted that, at the time of the March 2013 sleep study, the Veteran was obese, and that obstructive sleep apnea "is due to upper airway obstruction during sleep, often caused by obesity." The examiner referenced literature noting that "[i]n obese people, fat deposits in the upper respiratory tract narrow the airway; there is a decrease in muscle activity in this region, leading to hypoxic and apneic episodes, ultimately resulting in sleep apnea." The examiner found that the Veteran's risk factor of obesity "far outweighs the TERA."

Finally, the examiner provided opinions regarding secondary nexus to the hypertension. The examiner first opined that it was less likely than not that the obstructive sleep apnea was less likely than not proximately due to or the result of the service-connected hypertension. The examiner noted that sleep apnea and hypertension are "not medically related," and that the sleep apnea is "a separate entity entirely from the [hypertension] and unrelated to it." The examiner reviewed and referenced medical literature, which "failed to demonstrate a causal relationship." The examiner specifically referenced a journal article noting that "[w]hether hypertension contributes to [obstructive sleep apnea] remains unknown." Next, regarding aggravation, the examiner was unable to determine a baseline level of severity for the obstructive sleep apnea. However, the examiner found that it was less likely than not aggravated beyond the natural progression by the service-connected hypertension. The examiner again referred to medical literature, which did indicate that hypertension could aggravate obstructive sleep apnea.

Turning to analysis of the above opinions, the July 2019 examiner reviewed the claims file and provided a reasoned analysis based on consideration of the Veteran's statements and pertinent medical evidence regarding onset of his obstructive sleep apnea. While the rationale for the opinion is brief, it should be noted that the Veteran has not specifically contended that his obstructive sleep apnea, or symptoms thereof, had onset during service. The opinion is consistent with the above-noted STRs and post-service medical records regarding onset of obstructive sleep apnea. As such, the opinion is afforded at least some probative value as to direct nexus.

Next, the April 2024 examiner did not clearly distinguish between the concepts of causation and aggravation, diminishing the probative value of the opinion. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Nonetheless, the examiner provided alternative etiologies of obstructive sleep apnea based on review of pertinent literature, including obesity. As such, especially when considered with the August 2024 opinion, the April 2024 opinion is afforded at least low probative value as to secondary nexus.

Finally, the August 2024 examiner reviewed the claims file, finally acknowledging the Veteran's March 2013 diagnosis of obstructive sleep apnea via sleep study. Regarding non-TERA direct nexus, the examiner's opinion is largely consistent with the July 2019 examiner's opinion. In particular, the examiner relied on the Veteran's in- and post-service treatment records. As such, the opinion is afforded at least some probative value as to non-TERA direct nexus.

Similarly, regarding nexus to the in-service TERA, the examiner noted review of medical literature, and emphasized that the Veteran's obesity - for which the examiner provided a clear nexus to the diagnosis of sleep apnea - outweighed the TERA as a risk factor. The opinion is afforded significant probative value in this regard.

Finally, regarding secondary nexus to the service-connected hypertension, the examiner provided separate, clearly articulated opinions for causation and aggravation, again relying on pertinent medical literature in support. Although the examiner referred to "proximate" causation and aggravation "beyond the natural progression," it should be noted that the examiner did not find evidence of any causative relationship between obstructive sleep apnea and hypertension. As such, the standards of causation and aggravation applied by the examiner do not manifestly affect the adequacy or probative value of the opinion. Here, unlike in Spicer, the Veteran has not made any contentions regarding secondary nexus between obstructive sleep apnea and hypertension that would contemplate a broader degree of causality and/or aggravation, such as preclusion of a corrective medical procedure for a nonservice-connected disability due to use of a certain medication for treatment of a service-connected disability. Given the above, the examiner's use of language regarding proximate causation and aggravation beyond the natural progression was harmless error in this regard.

To the extent that the Veteran believes that his obstructive sleep apnea is secondary to his service-connected hypertension, his opinion is not competent in this regard. The issue is medically complex, and, therefore, is outside the competence of the Veteran, who has not been shown to possess the medical training or credentials to make such determinations. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428 (2011). As such, his opinion is afforded no probative value, and is outweighed by the more probative VA opinions of record.

Similarly, the Veteran's bare assertion in the February 23, 2025, NOD that his obstructive sleep apnea was secondary to his service-connected degenerative changes of the lumbar spine is not accompanied by any supporting evidence, and is also incompetent as evidence, and is afforded no probative value. Furthermore, as he included these contentions only with his February 23, 2025, NOD, there is no pre-decisional basis to remand the claim for development of this contention.

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Given the above, the evidence persuasively weighs against the finding that the Veteran's obstructive sleep apnea was incurred in or is otherwise related to service, or is caused or aggravated by the service-connected hypertension. Accordingly, service connection for obstructive sleep apnea is not warranted, and the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

L. B. CRYAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board D. Small, Attorney Advisor

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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