SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

M. SORISIO · 2026 · Case ID: A26011244

GRANTED

Summary

The veteran, who served from October 1981 to October 1985 and November 1988 to December 1998, appeals the denial of service connection for obstructive sleep apnea (OSA). The veteran claims OSA is secondary to his service-connected lumbar strain with degenerative arthritis and unspecified trauma and stressor-related disorder. He asserts these service-connected conditions limit his mobility and sleep quality, contributing to obesity, which in turn caused his OSA. A private medical opinion from Dr. Z.M. supported this claim, finding it at least as likely as not that the veteran's obesity was due to his service-connected conditions and that this obesity caused or aggravated his OSA. The Board found this opinion probative, noting its clear conclusion and rationale, despite some minor flaws. In contrast, two VA opinions were found inadequate; one failed to address the intermediate step of obesity as a cause of OSA and did not adequately consider the private opinion, while the other was deemed inconclusive and failed to address aggravation. Because the only probative opinion favored the veteran and the VA opinions were inadequate, the Board found the evidence in approximate balance. Applying the benefit of the doubt, service connection for OSA was granted.

Rationale

Private medical opinion found obesity to be an intermediate step caused by service-connected conditions, leading to OSA.; VA opinions were inadequate as they did not address the intermediate step of obesity or aggravation, and were not based on a complete review of evidence.; Evidence in approximate balance, with doubt resolved in veteran's favor.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250710-564003

Full Decision Text

Citation Nr: A26011244
Decision Date: 02/05/26 Archive Date: 02/05/26

DOCKET NO. 250710-564003
DATE: February 5, 2026

ORDER

Service connection for obstructive sleep apnea (OSA) is granted.

FINDINGS OF FACT

1. The Veteran's service-connected lumbar strain with degenerative arthritis and service-connected unspecified trauma and stressor-related disorder caused him to become obese.

2. The Veteran's obesity was a substantial factor in causing his sleep apnea and the sleep apnea would not have occurred but for obesity caused by the service-connected disabilities.

CONCLUSION OF LAW

The criteria for service connection for OSA as secondary to lumbar strain with degenerative arthritis and unspecified trauma and stressor-related disorder are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty from October 1981 to October 1985 and from November 1988 to December 1998.

The rating decision on appeal was issued in November 2024, with notification issued in December 2024, and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In July 2023, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of service connection for OSA, most recently addressed in a November 2015 rating decision. In December 2023, the agency of original jurisdiction (AOJ) issued the Supplemental Claim decision, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision.

In December 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of the December 2023 Supplemental Claim decision. In April 2024, the AOJ issued the HLR decision, after finding a duty to assist error in a December 2023 Supplemental Claim decision and transferred the claim to the Supplemental Claim decision review option for additional development. The August 2024 Supplemental Claim decision considered the evidence of record at the time of the prior December 2023 Supplemental Claim decision, in addition to the evidence added to the record after correcting the duty to assist error, and denied the claim based on the evidence of record at the time of that decision.

In August 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR and requested review of the August 2024 Supplemental Claim decision. In November 2024, the AOJ issued the HLR decision on appeal, which considered the evidence of record at the time of the prior August 2024 Supplemental Claim decision and denied the claim.

In a July 2025 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the August 2024 supplemental claim decision. 38 C.F.R. § 20.301. Any evidence submitted after that decision cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

Service Connection

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303.

Secondary service connection may be granted for a disability that is caused or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists, (2) that there is an already service-connected disability, and (3) that there is "but for" causation or aggravation of the disability for which service connection is sought by a service-connected disability. See Spicer v. McDonough, 61 F.4th 1360, 1363 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and holding "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Obesity may act as 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
show (1) that a current disability exists, (2) that there is an already service-connected disability, and (3) that there is "but for" causation or aggravation of the disability for which service connection is sought by a service-connected disability. See Spicer v. McDonough, 61 F.4th 1360, 1363 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and holding "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Obesity may act as 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(a).?VAOPGCPREC 1-2017; see Marcelino v. Shulkin, 29?Vet. App.?155?(2018); but see Adams v. Collins, 38 Vet. App. 273 (2025) (finding that VAOPGCPREC 1-2017 is an improper statutory interpretation as to whether obesity is a disability for purposes of secondary service connection).

In order to establish service connection on an "intermediate step" basis, three criteria must be met: (1) a service-connected disability or disabilities that caused the veteran to become obese; (2) the obesity was a substantial factor in causing another disability; and (3) the disability would not have occurred but for the obesity caused by the veteran's service-connected disability or disabilities. See VAOPGCPREC 1-2017.?

Service connection for OSA is granted.

The Veteran contends that he has OSA secondary to his service-connected lumbar strain with degenerative arthritis and unspecified trauma and stressor-related disorder. He reports that his service-connected lumbar strain with degenerative arthritis keeps him from exercising and prevents him from being able to sleep on his side. July 2023 Statement in Support of Claim. Additionally, the Veteran notes that his lumbar strain with degenerative arthritis pain makes it difficult to fall or stay asleep. Id. Relative to his service-connected unspecified trauma and stressor-related disorder, the Veteran indicates that his medication causes insomnia, leg kicks during sleep, dry mouth upon wakening, and nighttime sweating. Id.

The November 2024 rating decision made favorable findings that the Veteran was diagnosed with OSA and that the Veteran is service connected for lumbar strain with degenerative arthritis and unspecified trauma and stressor-related disorder. Additionally, the August 2024 rating decision made a favorable finding that the Veteran's OSA is secondary to his nonservice-connected obesity. The Board is bound by these favorable findings. 38 C.F.R. § 3.104.

In a July 2023 private medical opinion, Dr. Z.M., a Certified Sleep Medicine Medical Doctor, concluded that it is at least as likely as not that the Veteran's obesity is due to his service-related conditions, to include unspecified trauma and stressor-related disorder and lumbar strain with degenerative arthritis, and that the Veteran's obesity led to, caused, and/or aggravated the current OSA. In support of the opinion, Dr. Z.M. discussed that the Veteran's service-connected conditions can lead to or cause pain, painful motion, sleep disturbances (related to pain and forced sleep positions related to disabilities), diminished motivation, and/or comfort overeating, which can lead to diminished activity with less caloric expenditure, which leads to and/or promotes weight gain and obesity. Dr. Z.M. continued to discuss how medical literature documents that obesity is known to predispose patients to and directly cause OSA. While the opinion is not flawless, the opinion has a clear conclusion and rationale based on the provider's examination of the Veteran and his medical history and serves to link the claimed OSA to the service-connected lumbar strain with degenerative arthritis and unspecified trauma and stressor-related disorder. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Therefore, the Board assigns this opinion probative weight.

In November 2023, a VA clinician reviewed the Veteran's claims file and opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected conditions. The VA examiner rationalized that posttraumatic stress disorder was not a known risk factor for the development of OSA, and that known risk factors include obesity, age, craniofacial abnormalities, and upper airway abnormalities. In a May 2024 VA medical opinion, the same VA examiner further opined that there was insufficient evidence to suggest that the Veteran's unspecified trauma and stressor-related disorder and lumbar strain with degenerative arthritis resulted in the Veteran's OSA, as they are not known risk factors for OSA. The VA examiner noted that the Veteran's body mass index (BMI) was 33, which is considered class I obesity and that obesity is a known risk factor for OSA. These opinions are inadequate, as they do not address the relation, if any, between the Veteran's service-connected conditions and his obesity as an intermediate step. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (when determining service connection, all theories of entitlement reasonably raised by the evidence of record must be considered). Additionally, while the November 2023 opinion references the existence of the July 2023 private medical opinion, it does not appear to have considered the July 2023 private medical opinion and the medical literature considered therein when rendering negative nexus opinions. In this regard, the November 2023 and May 2024 VA medical opinions do not cite to or discuss any of the medical literature considered in the July 2023 private medical opinion and the November 2023 and May 2024 VA medical opinions do not discuss the findings or nexus of the July 2023 private medical opinion. Thus, it is unclear to the Board that the November 2023 and May 2024 VA medical opinions were based on a complete review of the relevant evidence and medical literature. Additionally, these opinions are inadequate as to causation, as a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision. Stefl, 21 Vet. App. at 124-25. Lastly, the examiner failed to address whether the Veteran's OSA was aggravated by the service-connected unspecified trauma and stressor-related disorder or his lumbar strain with degenerative arthritis. Therefore, the opinions are inadequate as related to whether the Veteran's OSA was aggravated by his service-connected unspecified trauma and stressor-related disorder or his service-connected lumbar strain with degenerative arthritis, as it did not address this question. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013) (finding that an examination was inadequate on the question of aggravation when aggravation was not addressed by the examiner). Thus, these opinions are entitled to no weight of probative value.

In December 2023, a different VA clinician reviewed the Veteran's claims file and opined that the claimed condition was less likely than not proximately due to, or the result of, the Veteran's service-connected lumbar strain with degenerative arthritis. The VA examiner rationalized that the private medical opinion and the literature therein failed to recognize that the cause of obesity or weight gain is multifactorial and has other risk factors, including dietary factors, physical inactivity, sleep patterns, smoking cessation, gut microbiome, and even medical conditions such as hypothyroidism or Cushing's Syndrome, genetics, cultural societal factors, and demographics, and that attributing the cause of the Veteran's obesity to a single particular etiology, such as diet alone or lack of exercise, would be speculative at best. The Board finds this opinion is inadequate. The clinician did not make clear whether the need to speculate was due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). See Jones v. Shinseki, 23 Vet. App. 382, 390-91 (2010) (explaining that an inconclusive medical opinion must be "adequately explained by the examiner or otherwise apparent in the Board's review of the evidence"); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Additionally, the opinion is inadequate as related to whether the Veteran's OSA was aggravated by his service-connected unspecified trauma and stressor-related disorder or his service-connected lumbar
(no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). See Jones v. Shinseki, 23 Vet. App. 382, 390-91 (2010) (explaining that an inconclusive medical opinion must be "adequately explained by the examiner or otherwise apparent in the Board's review of the evidence"); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Additionally, the opinion is inadequate as related to whether the Veteran's OSA was aggravated by his service-connected unspecified trauma and stressor-related disorder or his service-connected lumbar strain with degenerative arthritis, as it did not address this question. See El-Amin, 26 Vet. App. at 136. Thus, this opinion is also entitled to no weight of probative value.

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As such, since the only opinion entitled to weight of probative value favors a finding that the Veteran's OSA is caused by his service-connected lumbar strain with degenerative arthritis and unspecified trauma and stressor-related disorder, the Board finds the evidence is at least in approximate balance. Therefore, the Board resolves all reasonable doubt in the Veteran's favor and grants service connection for OSA. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

M. SORISIO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board K. Knerr

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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