SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, who served in the United States Air Force from December 1986 to November 2008, appealed the denial of service connection for obstructive sleep apnea (OSA) as secondary to service-connected persistent depressive disorder with anxious distress, left ulnar nerve neuropathy, and lumbosacral strain, with obesity as an intermediate step. The Veteran submitted lay statements detailing weight gain and attributing it to service-connected mental health and musculoskeletal conditions, which in turn allegedly led to OSA. A private medical opinion found it at least as likely as not that the Veteran's obesity was related to service-connected conditions and that OSA was secondary to this obesity, citing medical studies linking depression and pain to weight gain and sleep disturbance. Conversely, a VA examination concluded that OSA was less likely than not related to service-connected conditions, citing other risk factors like smoking and allergic rhinitis, and found obesity was less likely than not caused by service-connected disabilities. The Board found the private opinion persuasive, noting its detailed rationale and adherence to medical principles, and contrasted it with the VA examiner's less favorable opinion. Given the conflicting evidence and applying the benefit of the doubt doctrine, the Board granted service connection for OSA as secondary to the service-connected conditions, with obesity as an intermediate step.

Rationale

Private medical opinion found obesity related to service-connected conditions and OSA secondary to obesity.; VA opinion found OSA less likely than not related to service-connected conditions.; Board applied benefit of the doubt due to conflicting medical opinions.

Full Decision Text

Citation Nr: A26002032
Decision Date: 01/08/26	Archive Date: 01/08/26

DOCKET NO. 250604-553257
DATE: January 8, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain, with obesity as an intermediate step is granted.

FINDING OF FACT

Resolving all doubt in the Veteran's favor, it is at least as likely as not that the Veteran's OSA is proximately due or aggravated beyond its natural progression by the Veteran's service connected persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain, with obesity serving as an intermediate step.

CONCLUSION OF LAW

The criteria for entitlement to service connection for OSA as secondary to persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain, with obesity as an intermediate step have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served in the United States Air Force from December 1986 to November 2008. 

In December 2024, the AOJ in its rating decision continued its previous denial of service connection for OSA.

In the June 2025 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 December 2024 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 OSA as secondary to persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain, with obesity as an intermediate step is granted. 

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110.  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).

Secondary service connection shall be granted for a disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Also, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b).

The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In order for a medical opinion to be given weight, it must be: (1) based upon sufficient facts or data
 connected. 38 C.F.R. § 3.310(b).

The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In order for a medical opinion to be given weight, it must be: (1) based upon sufficient facts or data; (2) the opinion is the product of reliable principles and methods; and (3) the expert witness has applied the principles and methods reliable to the facts of the case. Nieves-Rodríguez v. Peake, 22 Vet. App. 295, 302 (2008). Other factors that may be considered in assessing the probative value of a medical opinion include a physician's access to the claims file or pertinent evidence, the thoroughness and detail of the opinion, the accuracy of the factual premise underlying the opinion, the scope of examination, the rationale for the opinion offered, the degree of certainty provided, and the qualifications and expertise of the examiner. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also, in terms of adequacy, failure to discuss both aspects of causation and aggravation in an opinion addressing secondary service connection renders the medical opinion inadequate. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). A report of a medical examination administered by a private physician that is provided by a claimant in support of a claim for benefits may be accepted without a requirement for confirmation by an examination by a physician employed by the Veterans Health Administration if the report is sufficiently complete to be adequate for the purpose of adjudicating such claim. 38 U.S.C. § 5125.

In circumstances when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). More precisely, the benefit-of-the-doubt rule applies if the competing evidence is in "approximate balance", which can be interpreted as evidence that is "nearly equal". Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021).

As a procedural starting point for this claim, in July 2023, the Veteran submitted a fully developed claim for service connection for OSA.

In July 2023, the Veteran submitted a statement in support of claim. The Veteran indicated that she weighed 130 lbs. at military entrance, 165 lbs. upon military separation, and that she currently weighs 198 lbs. Also, the Veteran commented that her musculoskeletal conditions prevent her from being able to sleep on her side. Moreover, the Veteran stated that due to her mental health condition and fatigue, she has been less motivated to exercise which has caused her weight gain. Furthermore, the Veteran cited her mental health condition as a reason for her poor food choices and tendency to eat high-calorie foods.

In July 2023, a private examiner opined that it is at least as likely as not that the Veteran's weight gain and obesity is due to and/or related to her service connected persistent depressive disorder with anxious distress, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain. Also, the private examiner determined that it is at least as likely as not that the Veteran's OSA condition with CPAP is secondary to, related to, and/or aggravated by the weight gain and obesity from the service connected persistent depressive disorder with anxious distress, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain. Moreover, the private examiner concluded that it is at least as likely as not that without the Veteran's weight gain and obesity, her OSA would not have occurred.

The private examiner cited that the Veteran has had progressive weight gain and a current obesity condition which developed after the in-service mental health stressors and musculoskeletal symptomatology. The private examiner indicated that recent studies support the idea that depression induces weight gain and obesity. In addition, the private examiner highlighted that due to the persistent pain of her service connected left ulnar nerve neuropathy and lumbosacral strain, the Veteran was unable to be as active as she was before her musculoskeletal conditions and subsequently began to progressively gain weight. Moreover, the private examiner stated that evidence suggests that pain and
 private examiner concluded that it is at least as likely as not that without the Veteran's weight gain and obesity, her OSA would not have occurred.

The private examiner cited that the Veteran has had progressive weight gain and a current obesity condition which developed after the in-service mental health stressors and musculoskeletal symptomatology. The private examiner indicated that recent studies support the idea that depression induces weight gain and obesity. In addition, the private examiner highlighted that due to the persistent pain of her service connected left ulnar nerve neuropathy and lumbosacral strain, the Veteran was unable to be as active as she was before her musculoskeletal conditions and subsequently began to progressively gain weight. Moreover, the private examiner stated that evidence suggests that pain and sleep exist in a bidirectional relationship in which pain causes sleep disturbance and sleep disturbance intensifies pain. The private examiner noted that partial sleep loss may increase the risk of obesity and weight gain.

In July 2023, the AOJ in its rating decision denied service connection for sleep apnea.

In July 2024, the Veteran submitted a supplemental claim for service connection for OSA as secondary to persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, lumbosacral strain, and associated weight gain/obesity.

In November 2024, the Veteran underwent a sleep apnea VA examination. The VA examiner noted a diagnosis of obstructive sleep apnea.

In November 2024, the VA examiner opined that the Veteran's OSA is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service connected conditions. The VA examiner indicated that the Veteran has multiple risk factors for the development of OSA to include a history of chronic nasal congestion as evidenced by a diagnosis of allergic rhinitis and history of smoking. Also, the VA examiner determined that the Veteran's OSA was less likely than not aggravated beyond its natural progression by the Veteran's service connected conditions. The VA examiner insisted that the Veteran's obesity was less likely than not a result of the Veteran's service connected disabilities. Moreover, the VA examiner cited the Veteran's history of smoking and allergic rhinitis as possible factors.

In November 2024, the VA examiner opined that the Veteran's OSA is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of persistent depressive disorder with anxious distress, lumbosacral strain, and/or left ulnar nerve release. The VA examiner listed risk factors such as obesity, older age, narrowed airway, hypertension, chronic nasal congestion, smoking, diabetes, male sex, family history, and asthma. Also, the VA examiner highlighted that the Veteran has risk factors of obesity, nasal congestion, and smoking. Moreover, the VA examiner remarked that there is no evidence in the Veteran's medical records nor the medical literature to suggest that constructive sleep apnea is due to lumbosacral strain, persistent depressive disorder with anxious distress or left ulnar nerve neuropathy.

In November 2024, the VA examiner opined that the Veteran's OSA is not at least as likely as not aggravated beyond its natural progression by her service connected conditions. The VA examiner listed risk factors such as obesity, older age, narrowed airway, hypertension, chronic nasal congestion, smoking, diabetes, male sex, family history, and asthma. Also, the VA examiner highlighted that the Veteran has risk factors besides obesity such as nasal congestion and smoking. The VA examiner stated that saying that the Veteran's OSA is solely due to the Veteran's obesity would be a mere speculation.

In November 2024, the VA examiner opined that the Veteran's service connected disabilities were less likely than not (likelihood is less than approximately balanced or nearly equal) to have caused the Veteran to become obese. The VA examiner highlighted that obesity is a complex disease involving a combination of factors to include environmental, genetics, medications, psychological factors, diseases, hormones and bacteria, and lifestyle choices. Also, the VA examiner stated that there is no evidence in the medical records to support that the Veteran's service connected conditions lead to an impaired ability for the Veteran to make proper food choices. The VA examiner explained that a 2015 study found that diet plays a larger role in obesity than physical activity. Moreover, the VA examiner remarked that even with the inability to perform high impact activities of walking or running, an individual can participate in other activities such as yoga or swimming that are low impact in order to be less sedentary.

In December 2024, the AOJ in its rating decision continued its previous denial of service connection for OSA. The AOJ indicated that it did not find a link between the medical condition and military service. As favorable findings, the AOJ noted that the Veteran has been diagnosed with OSA. Also
 Veteran's service connected conditions lead to an impaired ability for the Veteran to make proper food choices. The VA examiner explained that a 2015 study found that diet plays a larger role in obesity than physical activity. Moreover, the VA examiner remarked that even with the inability to perform high impact activities of walking or running, an individual can participate in other activities such as yoga or swimming that are low impact in order to be less sedentary.

In December 2024, the AOJ in its rating decision continued its previous denial of service connection for OSA. The AOJ indicated that it did not find a link between the medical condition and military service. As favorable findings, the AOJ noted that the Veteran has been diagnosed with OSA. Also, the AOJ highlighted that the primary disabilities of persistent depressive disorder with anxious distress; lumbosacral strain; and left ulnar nerve neuropathy post ulnar nerve release are service connected.

In June 2025, the Veteran submitted a VA Form 10182 Notice of Disagreement.

Upon review of the evidence of record, the Board finds that service connection for OSA as secondary to persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain, with obesity as an intermediate step is granted. It is important to highlight that the AOJ has conceded that the Veteran has been diagnosed with OSA. Also, the AOJ noted that the Veteran's primary disabilities of persistent depressive disorder with anxious distress; lumbosacral strain; and left ulnar nerve neuropathy post ulnar nerve release are service connected. The Board is bound by these favorable findings. 

In this case, there are various contrasting medical opinions which discuss whether the Veteran's OSA would not have been diagnosed but for obesity, or the aggravation of obesity. Thus, this implicates a theory of secondary service connection with obesity as an intermediate step between the service connected disabilities of persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain and his diagnosed disability of OSA. VAOPGCPREC 1-2017. Although obesity is not considered a disability for which consideration may be granted, VA's General Counsel has concluded that, under certain circumstances, obesity may be 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. For example, according to the General Counsel, some veterans could potentially be eligible for service connection for hypertension on a secondary basis if a service-connected back disability causes obesity due to lack of exercise, which can then lead to hypertension. VAOPGCPREC 1-2017, at 9. With regard to this hypothetical claim, VA's General Counsel wrote that, adjudicators would have to resolve the following issues: (1) whether the service connected back disability caused the Veteran to become obese; (2) if so, whether the obesity as a result of the service connected disability was a substantial factor in causing hypertension; and (3) whether the hypertension would not have occurred but for the obesity caused by the service connected back disability. If these questions are answered in the affirmative, the hypertension may be service connected on secondary basis.

The Board seeks to perform the above-mentioned analysis specified by VA's General Counsel. For the first part of the analysis, the July 2023 private medical opinion determined that it is at least as likely as not that the Veteran's obesity is due to and/or related to her service connected disabilities. Based on the review of the record, the private examiner deemed that the Veteran had progressive weight gain that ultimately led her to become obese after the mental health stressors and musculoskeletal symptomatology first manifested in active service. Also, the private examiner highlighted that medical studies have shown that depression induces weight gain and obesity. This is in contrast to the November 2024 VA medical opinion which stated that the Veteran's service connected conditions did not lead her to an impaired ability to make proper food choices. However, the VA examiner acknowledged that psychological factors can be attributed to obesity. 

In terms of the second part of the analysis, the private examiner opined that the Veteran's OSA is related to and/or aggravated by the obesity caused by the service connected conditions. The private examiner explained that obesity has been associated with functional impairment and weakening in the upper airway muscles. Likewise, the VA examiner mentioned that obesity is a risk factor in the development and/or aggravation of OSA. 

In regard to the third part of the analysis, the private examiner clearly stated that it is at least as likely as not that without the Veteran's weight gain and obesity, her OSA would not have occurred. The private examiner cited that multiple studies have documented that obesity is known to predispose patients to
 factors can be attributed to obesity. 

In terms of the second part of the analysis, the private examiner opined that the Veteran's OSA is related to and/or aggravated by the obesity caused by the service connected conditions. The private examiner explained that obesity has been associated with functional impairment and weakening in the upper airway muscles. Likewise, the VA examiner mentioned that obesity is a risk factor in the development and/or aggravation of OSA. 

In regard to the third part of the analysis, the private examiner clearly stated that it is at least as likely as not that without the Veteran's weight gain and obesity, her OSA would not have occurred. The private examiner cited that multiple studies have documented that obesity is known to predispose patients to OSA. Also, the private examiner highlighted the high prevalence of OSA in patients with high body mass index. The Board finds that this medical opinion is highly persuasive. The July 2023 private medical opinion is based on a review of the record, applied reliable principles, and is supported by a reasonable rationale.

Given the foregoing and taking into consideration the discrepancy between the July 2023 private medical opinion and the November 2024 VA medical opinions in terms of whether secondary service connection using obesity as an intermediate step is warranted, the Board adheres to the rule that the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance. See Lynch v. McDonough, supra. Thus, the Board finds that the claim must be granted and that all doubt can be resolved in the Veteran's favor to find that it is at least likely as not that the Veteran's OSA is proximately due or aggravated beyond its natural progression by the Veteran's service connected persistent depressive disorder with anxious distress associated with migraine headaches, left ulnar nerve neuropathy status post ulnar nerve release, and lumbosacral strain with obesity serving as an intermediate step. 

 

DAVID L. WIGHT

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Colon, Ivan M.

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.