SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran, who served from October 1970 to October 1974, appeals the denial of service connection for obstructive sleep apnea (OSA) and seeks a higher disability rating for his service-connected hypertension. Regarding OSA, the veteran provided lay statements from fellow service members and his wife alleging sleep disturbances during service and after marriage, and submitted medical research linking OSA to other conditions. However, the service treatment records did not mention sleep disturbances, and the veteran denied trouble sleeping at service separation. VA examinations provided conflicting initial opinions but ultimately concluded, based on the lack of in-service diagnosis, chronicity, and the presence of risk factors like obesity and alcohol consumption, that OSA was less likely than not related to service. The Board found the medical opinions against service connection persuasive, noting that while lay statements and research articles were considered, they did not establish a causal link to service or service-connected conditions. Service connection for OSA was denied. For hypertension, the veteran sought a higher rating. The Board reviewed the service separation examination records, which showed blood pressure readings with diastolic pressure of 100 or more. Applying Diagnostic Code 7101, the Board found that the Veteran's history of diastolic pressure predominantly 100 or more, requiring continuous medication, warranted a 10 percent disability rating, which was granted. The Board found no evidence to support a higher rating.

Rationale

Service treatment records negative for sleep disturbances.; VA examinations ultimately opined OSA less likely than not related to service.; Lay statements and research articles did not establish causal link to service or service-connected conditions.

Full Decision Text

Citation Nr: A26018563
Decision Date: 03/02/26	Archive Date: 03/02/26

DOCKET NO. 250618-555192
DATE: March 2, 2026

ORDER

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

Entitlement to a compensable disability rating for hypertension is granted.

FINDINGS OF FACT

1. The evidence is persuasively against a finding that the Veteran's OSA had its onset in service or is otherwise due to service or a service-connected disability. 

2. The evidence shows that the Veteran's hypertension was historically manifested by blood pressure readings predominantly higher than 100 diastolic and he currently requires continuous medication to control his symptoms. 

CONCLUSIONS OF LAW

1. The criteria for service connection for obstructive sleep apnea (OSA) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for entitlement to a compensable disability rating for hypertension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.104, Diagnostic Code 7101.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty military service from October 1970 to October 1974.

This matter comes before the Board on appeal of rating decisions issued in May 2025 and June 2025 which denied a compensable disability rating for hypertension service connection for OSA, respectively. In the June 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. In July 2025 he submitted a new VA Form 10182 and selected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the May 2025 and June 2025 agency of original jurisdiction (AOJ) decisions on appeal, as well as any evidence submitted by the Veteran with, or within 90 days from receipt of, the second VA Form 10182 dated in July 2025. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. 

Service connection for obstructive sleep apnea (OSA) 

The Veteran seeks service connection for obstructive sleep apnea (OSA), which he asserts had its onset in service and/or is related to his service-connected hypertension and allergic rhinitis. Specifically, the Veteran has provided statements that while in boot camp he was informed by other service members that he made noises in his sleep like two bricks rubbing together, which he attributes to bruxism or teeth grinding. (See Correspondence, 02/24/2023.) He has also stated that prior to service he lived in the college dorms and his roommate never reported that he made noises in his sleep. He has provided a statement from his wife stating that he has a history of snoring and teeth grinding since they were married in 1981. (See Statement in Support, 02/24/2023.) During that time, the Veteran's wife noticed that he would sometimes stop breathing and she would have to nudge him to wake up and start breathing again. It took many years for her to convince him to get tested for sleep apnea. 

Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted.

When there is an approximate balance of positive and negative admissible evidence regarding any issue material to the determination of a matter, the evidence is said to be in equipoise. In such situations, VA is required to afford the Veteran the benefit of the doubt. 38 U.S.C. § 
 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, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted.

When there is an approximate balance of positive and negative admissible evidence regarding any issue material to the determination of a matter, the evidence is said to be in equipoise. In such situations, VA is required to afford the Veteran the benefit of the doubt. 38 U.S.C. § 5107 (b). In 2021, the Federal Circuit Court provided additional guidance on the standard for achieving equipoise has been relaxed. It is only necessary that the record come close to reaching a balance of positive and negative evidence; exact balance is not required. Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021).

Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. VA has amended 38 C.F.R. § 3.310 to reflect that it will not concede aggravation unless certain additional conditions are met. 38 C.F.R. § 3.310 (b).

The Veteran has a clear diagnosis of OSA as a current disability, having been diagnosed in 2010. The remaining aspects of his claim which remain to be addressed include whether the disability had its onset in service, whether it is due to or the result of his service, and whether it is caused or aggravated by any service-connected disability.

The service treatment records do not reflect any complaints or treatment for sleep disturbance or unusual symptoms in his sleep. At the time of service separation in September 1974, the Veteran completed a report of medical history and answered "No" to the question about experiencing frequent trouble sleeping. (See STR, 04/15/2015.) 

The Veteran underwent a VA examination in September 2023, which considered the his reports of symptoms in service, including making unusual noises in his sleep. (See C&P Exam, 09/23/2023.) The examiner noted that the Veteran had been diagnosed in 2010 and had been prescribed a CPAP machine which he used regularly. The examiner initially offered the opinion that the Veteran's OSA was at least as likely as not caused by his military service, stating that the Veteran did not have OSA prior to service, there was evidence of chronicity and the Veteran had sleep disturbances prior to his diagnosis in 2010. 

In July 2024, the AOJ sought a clarifying addendum opinion from the examiner, asking about the rationale regarding evidence of chronicity of sleep disturbances. (See C&P Exam, 07/30/2024.) The AOJ noted that the Veteran had denied trouble sleeping at the time of service separation and any sleep disturbances reported in 1979 would have been five years after service separation. The examiner reviewed the medical evidence and noted that in a treatment note from December 1998, the Veteran had denied any significant sleep disturbances. In fact, the first mention of sleep disturbance in the medical record was from 2010. The examiner offered the opinion that any sleep disturbances the Veteran might have experienced in service did not mean that the he had OSA at that time and could have been due to lifestyle, medications, diet, or other health conditions. The examiner described the physical mechanisms related to OSA including narrowing or collapse of the airway or anatomical variations in the neck structure and often are the result of excess weight and the aging process. Based on the fact that OSA was not diagnosed until 30 years after service separation and the fact that the Veteran had the risk factor of obesity, the examiner offered the opinion that the evidence was not approximately equal as to the etiology. The examiner provided the opinion that the Veteran's OSA was less likely than not related to his military service. 

In August 2024, the AOJ obtained an expert medical opinion regarding the Veteran's OSA claim. (See C&P Exam, 08/27/2024.) The expert opinion was that the Veteran's OSA was not due to his military service because it was diagnosed 35 years after service separation. The expert noted that lay statements had been considered and acknowledged the reports that the Veteran was noted to make strange sounds in his sleep while in service. However, making strange sounds during sleep does not equate to OSA and the Veteran had not reported any problems sleeping in service or
 approximately equal as to the etiology. The examiner provided the opinion that the Veteran's OSA was less likely than not related to his military service. 

In August 2024, the AOJ obtained an expert medical opinion regarding the Veteran's OSA claim. (See C&P Exam, 08/27/2024.) The expert opinion was that the Veteran's OSA was not due to his military service because it was diagnosed 35 years after service separation. The expert noted that lay statements had been considered and acknowledged the reports that the Veteran was noted to make strange sounds in his sleep while in service. However, making strange sounds during sleep does not equate to OSA and the Veteran had not reported any problems sleeping in service or on the service separation examination. The expert stated that there was no evidence of chronicity in service, the Veteran's OSA was more likely to be due to a post-service event, illness, or injury.

In September 2024, the AOJ obtained an addendum opinion to specifically address the question of secondary service connection for OSA. (See C&P Exam, 09/29/2024.) The expert was asked if the Veteran's OSA had been caused or aggravated by his service-connected hypertension. The expert noted that at the time the Veteran was diagnosed with OSA he had a BMI of 32.9 and that in 2021 he had a BMI of 33.5 and reported a history of alcohol consumption. The expert noted that a 10 percent increase in weight increased the risk of OSA sixfold and that alcohol consumption resulted in the relaxation of muscles in the mouth and throat which could close the upper airway. The expert noted that the Veteran had the risk factors of obesity and alcohol consumption. The expert offered the opinion that the Veteran's OSA was less likely than not caused or aggravated by his service-connected hypertension. 

The Veteran submitted a Disability Benefits Questionnaire (DBQ) completed by his primary care physician in February 2025. (See DBQ, 02/10/2025.) The provider noted that the Veteran had been symptomatic for OSA prior to his diagnosis in 2010 and that he regularly used a CPAP machine. The provider indicated that the Veteran experienced functional limitations related to his OSA because it made wakefulness more difficult and caused issues with concentration and focus. The DBQ form did not include a section for a nexus opinion, and the provider did not offer an opinion as to any relationship between OSA and the Veteran's military service or service-connected disabilities.

Another VA expert medical opinion was obtained in June 2025 addressing whether the Veteran's OSA was caused or aggravated by his allergic rhinitis. (See C&P Exam, 06/05/2025.) The medical expert conceded that individuals with allergic rhinitis have an increased risk of sleep apnea and that nasal obstruction is also associated with increased risk. However, the expert noted that there is no causal link between OSA and allergic rhinitis or between nasal obstruction and OSA. Based on the fact that no causal relationship has been shown, the VA expert offered the opinion that the Veteran's OSA was not caused by his allergic rhinitis. The expert noted that the most important risk facts are advancing age, male gender, and obesity, al of which the Veteran has. In addition, OSA is shown to be dependent on factors that affect the loose, floppy tissue of the throat, such as obesity. 

In correspondence submitted in July 2025, the Veteran contended that evidence of record had not yet been addressed in his ongoing claim for OSA. (See Correspondence, 07/21/2025.) He asserted that no one had addressed the 1981 buddy statement about the noises he made in his sleep or having stopped breathing, or the private medical records showing treatment for raspy voice, postnasal drip, and snoring. He referenced that he had undergone surgeries including cauterization of the sinus, microlaryngoscopy, removal of vocal cord leukoplakia, and nasal cautery of the turbinates. He also noted that there had been no consideration of his prescription medications for allergy or that he had nasal congestion. He stated that his doctor had considered whether he had a more severe condition but had ruled that out after the surgical procedures he mentioned. And he noted that studies showed that OSA occurred twice as often in those who have nighttime nasal congestion. Finally, he asserted that his personal care provider was more highly qualified than the nurse practitioners who had completed the VA examinations and opinions and his statements should be entitled to greater consideration as a result. 

The Veteran also submitted copies of articles about hypertension and sinusitis or rhinitis and OSA and the relationships between these conditions which he felt should be considered. (See Correspondence, 07/23/2025.) He noted that the articles showed
 of his prescription medications for allergy or that he had nasal congestion. He stated that his doctor had considered whether he had a more severe condition but had ruled that out after the surgical procedures he mentioned. And he noted that studies showed that OSA occurred twice as often in those who have nighttime nasal congestion. Finally, he asserted that his personal care provider was more highly qualified than the nurse practitioners who had completed the VA examinations and opinions and his statements should be entitled to greater consideration as a result. 

The Veteran also submitted copies of articles about hypertension and sinusitis or rhinitis and OSA and the relationships between these conditions which he felt should be considered. (See Correspondence, 07/23/2025.) He noted that the articles showed that people with chronic rhinosinusitis were 80 percent more likely to have OSA, that people with OSA were more likely to have hypertension, and that people with OSA were found to have higher rates of anxiety. He asserted that, based on the articles, hypertension and allergy rhinitis were prime causes of OSA and he was service-connected for both. He asserted that the reason his OSA had not been diagnosed in 1974 was because it wasn't a disorder that was medically treated until the 1990s. He asserted that possible causes of his OSA included breaking his leg in boot camp, anxiety and stress related to his duties in a military hospital, or being sent to Vietnam. 

The Board has considered all evidence of record with specific attention to the documents discussed above. After due consideration, the Board finds that the evidence is persuasively against the claim of service connection, to include as secondary to a service-connected disability.  

The Veteran is sincere in his belief that he had exhibited symptoms of OSA in service and links this to the amount of stress and anxiety he experienced in service. He has reported being told that he made unusual noises in his sleep during boot camp and that he has snored throughout his marriage. He has submitted medical research articles showing that teeth grinding is frequently manifested in people with OSA. The Veteran has also asserted that he is being penalized because OSA was not known at the time of his service or for many years afterward. The Board acknowledges that a sleep test or polysomnography is considered the primary means of diagnosing OSA and that the VA examiners have pointed to the lack of such a test as evidence against an earlier diagnosis. However, the Board is basing its decision on the totality of the evidence, which includes the medical opinions obtained, as well as the lay statements.

The Board has considered the medical research and articles submitted by the Veteran about the possible relationships between OSA and hypertension or allergic rhinitis or even anxiety. These articles are informative, but they are not determinative because none of them state that OSA is caused by any of the Veteran's other health conditions. The research shows that people with hypertension or anxiety or allergic rhinitis all have higher incidences of OSA, but they do not show that there is a causal relationship between those disabilities and OSA. The medical experts who have provided opinions have stated that the current state of medical knowledge finds the risk factors of gender and age and, most particularly, obesity to have the strongest causal connection to OSA. "The term 'risk factor' is defined as 'a clearly defined occurrence that has been associated with the increased rate of a subsequently occurring disease; causality may or may not be implied.'" See Lloyd v. McDonald, No. 15-1487, (Vet. App. June 13, 2016) (citing DORLAND'S at 676).  Additionally, the articles are general in nature and are not based on the facts and history specific to the Veteran's claim, reducing or removing their probative value in establishing nexus.  Sacks v. West, 11 Vet. App. 314, 317 (1998)

The Board is required to base its decisions on the totality of the evidence and must rely on competent medical evidence to support the decisions made, rather than imposing its own opinions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991.) In this instance, the medical opinions of record are against a finding that the Veteran's OSA had its onset in service or is otherwise due to service or a service-connected opinion. The VA expert medical opinions have noted that while the symptoms exhibited in service and since service, to include those discussed in the 1981 buddy statement and the statement of the Veteran's wife, might be indicative of OSA, they are not sufficient for a retrospective diagnosis because they might be attributable to other causes. In particular, snoring, while often a symptom of OSA, is not sufficient to diagnose OSA. The only medical opinion indicating a link between the Veteran's service and his current OSA diagnosis was that of
. App. 171 (1991.) In this instance, the medical opinions of record are against a finding that the Veteran's OSA had its onset in service or is otherwise due to service or a service-connected opinion. The VA expert medical opinions have noted that while the symptoms exhibited in service and since service, to include those discussed in the 1981 buddy statement and the statement of the Veteran's wife, might be indicative of OSA, they are not sufficient for a retrospective diagnosis because they might be attributable to other causes. In particular, snoring, while often a symptom of OSA, is not sufficient to diagnose OSA. The only medical opinion indicating a link between the Veteran's service and his current OSA diagnosis was that of the September 2023 VA examination, which was changed in the addendum opinion based on additional considerations, including the Veteran denying difficulty sleeping at the time of service separation. The addendum opinion also noted that the Veteran's diagnosis of OSA was nearly 30 years following service separation; other VA expert opinions agree that this is evidence against service connection. The Veteran's primary care physician has submitted DBQ in February 2025 affirming the OSA diagnosis and providing evidence about the resulting functional impairment. However, the DBQ did not include an opinion on the cause of the Veteran's OSA to include linking it to his service or to a service-connected disability.

For the reasons discussed above, the Board finds that the criteria for service connection for OSA on either a direct or secondary basis have not been met. The medical evidence does not support a conclusion that the disability is causally linked to the Veteran's military service or to any service-connected disabilities. As such, the claim is denied.  

Entitlement to a compensable disability rating for hypertension

The Veteran is seeking a higher disability rating for his hypertension because he asserts that he still experiences high blood pressure readings despite taking his medication consistently. 

Hypertension is rated pursuant to 38?C.F.R. §?4.104, Diagnostic Code 7101, for hypertensive vascular disease (hypertension and isolated systolic hypertension).  Under Diagnostic Code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; it is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more.  A 40 percent rating is warranted for diastolic pressure predominantly 120 or more.  A 60 percent rating is warranted for diastolic pressure predominantly 130 or more. 

The language of Diagnostic Code 7101 includes consideration of the Veteran's history of symptoms, assigning a 10 percent disability rating where the Veteran requires continuous medication to control his hypertension and has a history of diastolic blood pressure which was 100 or more. In the Veteran's case, this provision is significant.

The record shows that the Veteran was diagnosed with benign essential hypertension at his service separation examination in September 1974. (See STR, 04/15/2015.) At that examination, the Veteran's blood pressure readings were recorded as 138/100, 132/101, and 140/104. He was immediately referred for treatment where the provider noted that the Veteran's blood pressure readings over the previous 5 days had included diastolic pressures between 98 and 104. At that treatment visit, his blood pressure readings were recorded as 140/104, 140/102, and a supine reading of 135/90. He was prescribed medication to treat this condition. 

The question before the Board is whether the record shows that the Veteran has a history of blood pressure readings where the diastolic pressure was predominantly 100 or more. The term "predominant" is not defined in the rating criteria. Merriam-Webster defines predominant to mean "being most frequent or common." See, e.g., "predominant," Merriam-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant.

At the time of the Veteran's separation from service, when he was diagnosed with benign essential hypertension, three blood pressure readings were recorded. All three included diastolic pressure of 100 or more. When examined and treated immediately thereafter, of the three blood pressure readings obtained, two showed diastolic pressure of 100 or more. The provider also noted that the Veteran's pressures in the five days before the visit, his readings had shown diastolic pressures between 98 and 104. Inasmuch as those specific readings are not included, the Board cannot determine whether a diastolic pressure of 100 or more was
-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant.

At the time of the Veteran's separation from service, when he was diagnosed with benign essential hypertension, three blood pressure readings were recorded. All three included diastolic pressure of 100 or more. When examined and treated immediately thereafter, of the three blood pressure readings obtained, two showed diastolic pressure of 100 or more. The provider also noted that the Veteran's pressures in the five days before the visit, his readings had shown diastolic pressures between 98 and 104. Inasmuch as those specific readings are not included, the Board cannot determine whether a diastolic pressure of 100 or more was predominant among them, but notes that at least one reading over 100 was included. Of the six recorded blood pressure readings between diagnosis and prescription of the medication, 5 of the 6 showed diastolic readings of 100 or more. The Board finds that this satisfies the definition of predominant as included in the relevant diagnostic code. 

The Board acknowledges that the Veteran's recorded blood pressure readings were within the diagnostic code criteria for only a brief period of time. However, the Board finds no reason that the Veteran should be penalized for the swiftness with which his condition was diagnosed or treated. The rating criteria do not set a time frame over which the predominant blood pressure readings should or must occur. 

Based on the evidence of record, the Board finds that a 10 percent disability rating for hypertension is warranted and the claim is granted. 38 C.F.R. § 4.31.

The Board has considered the question of whether a still higher, or 20 percent, disability rating is warranted for hypertension. The Board has considered the evidence of blood pressure readings during the current appeals period and finds no evidence of blood pressure readings where the systolic pressures were predominantly 200 or more or diastolic pressures were predominantly 110 or more. As such, the criteria for a disability rating greater than 10 percent have not been met. 38 C.F.R. § 4.31.

The Board notes that its jurisdiction is limited to the time frame of the current appeal. The Veteran has expressed his belief that his desired increased disability rating should be retroactive. Such a determination on the part of the Board would require a separate claim and consideration of a separate legal standard. Therefore, the current determination is only applicable to the current claims period during which there was continuous pursuit as set forth by the relevant law and regulations. 

 

 

Eric S. Leboff

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Handy, Cheryl E.

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.