SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran, who served in the United States Marine Corps from July 1999 to July 2003 and briefly in the United States Army in October 2003, appealed the denial of service connection for sleep apnea and hypertension. The veteran claimed these conditions were secondary to his service-connected PTSD and hypothyroidism. The Board reviewed evidence including a private medical opinion from Dr. B.V. and a VA examination. Dr. B.V. opined that PTSD and its medications could cause or aggravate sleep apnea and hypertension through mechanisms like REM sleep disruption, inflammation, and weight gain. The VA examiner, however, found less likely than not that sleep apnea was related to PTSD, attributing it to obesity but could not link the obesity to service-connected PTSD. For hypertension, the VA examiner provided a negative opinion for PTSD connection but acknowledged obesity as a factor, though unable to link it to PTSD or hypothyroidism. The Board found the VA opinion for sleep apnea had limited probative value due to lack of specific rationale and failure to address aggravation. Conversely, Dr. B.V.'s opinion was given significant weight for its thoroughness, consideration of the claims file, and discussion of the nexus between PTSD, stress, and sleep apnea. The Board found the evidence in approximate balance for both conditions and resolved doubt in the veteran's favor. Service connection for sleep apnea as secondary to PTSD was granted. For hypertension, the Board found it warranted secondary to PTSD via obesity as an intermediate step, citing research and the private opinion, and granted service connection.

Rationale

Private medical opinion found clear nexus between PTSD and sleep apnea.; VA opinion had limited probative value due to lack of specific rationale.; Benefit of the doubt resolved in veteran's favor.

Full Decision Text

Citation Nr: A26023051
Decision Date: 03/13/26	Archive Date: 03/13/26

DOCKET NO. 210310-145554
DATE: March 13, 2026

ORDER

Service connection for sleep apnea, as secondary to the service-connected mental health disorder, is granted.

Service connection for hypertension, as secondary to the service-connected mental health disorder, is granted.

FINDINGS OF FACT

1. The evidence is at least in approximate balance as to whether the Veteran's obstructive sleep apnea (OSA) is secondarily related to his active service.

2. The evidence is at least in approximate balance as to whether the Veteran's hypertension is secondarily related to his active service.

CONCLUSIONS OF LAW

1. Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for OSA have been met. 38 U.S.C. §§ 1112, 1113, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1112, 1113, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Marine Corps from July 1999 to July 2003, and in the United States Army from October 2003 to November 2003. 

This matter is before the Board on appeal from a March 2021 Appeals Modernization Act (AMA) rating decision that considered the evidence of record on that date.

The Veteran timely appealed this decision to the Board in March 2021 by submitting a VA Form 10182 Notice of Disagreement and selected the AMA Hearing Docket Lane, requesting a Board hearing and a re-evaluation of the evidence considered by the Agency of Original Jurisdiction (AOJ). By way of his docket selection, the Veteran had 90 days to submit any additional evidence for review following the hearing.

A Board hearing was scheduled for August 2024, but the Veteran withdrew his request for the hearing in June 2024. Therefore, the Board may only consider the evidence of record at the time of the March 2021 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative within 90 days following the June 2024 receipt of the withdrawal of the hearing request. 38 C.F.R. § 20.302(b). If evidence was submitted either (1) during the period after the AOJ issued the March 2021 rating decision and prior to the June 2024 receipt of the withdrawal, or (2) more than 90 days following the June 2024 receipt of the withdrawal, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(b), 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[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- Legal Criteria 

Service connection may be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a).  Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown.  38 C.F.R. § 3.310; El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Allen v. Brown, 7 Vet. App. 439 (1995).

Although obesity is not a condition for which service connection may be granted, obesity may qualify as an "intermediate step" between a service-connected disability and another current disability.  See VAOPGCPREC 1-2017; see also Garner v. Tran, 33 Vet. App. 241 (2021); Walsh v. Wilkie, 32 Vet. App. 300 (2020).  In a secondary service connection claim, a theory of obesity as an intermediate step is
38 C.F.R. § 3.310; El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Allen v. Brown, 7 Vet. App. 439 (1995).

Although obesity is not a condition for which service connection may be granted, obesity may qualify as an "intermediate step" between a service-connected disability and another current disability.  See VAOPGCPREC 1-2017; see also Garner v. Tran, 33 Vet. App. 241 (2021); Walsh v. Wilkie, 32 Vet. App. 300 (2020).  In a secondary service connection claim, a theory of obesity as an intermediate step is raised when there is some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition.  Garner v. Tran, 33 Vet. App. 241 (2021).

1. Service connection for sleep apnea, as secondary to the service-connected mental health disorder is granted. 

The Veteran contends that his sleep apnea is related to his active-duty service, to include as secondary to his service-connected posttraumatic stress disorder (PTSD) and hypothyroidism. The Board notes that the Veteran has been service-connected for PTSD, effective from June 2016. For the reasons explained below, the Board finds that service-connection for sleep apnea is warranted as secondary to the service-connected PTSD.

Turning to the evidence of record, a private medical opinion from Dr. B.V. was added to the claims file in August 2020. The examiner noted that in his professional career he has worked as a VA credential psychologist through the Veteran Evaluation Service. He also stated that he had performed hundreds of VA Independent Medical Examinations and DBQs. The examiner noted a review of the entire claims file. As it relates specifically to sleep apnea, Dr. B.V. noted the Veteran's lay reports that his PTSD symptoms caused him to toss and turn at night, as well as wake up in the night super alert and vigilant. The examiner explained that many VA examiners deny sleep apnea as being secondary to PTSD because they focus on anatomy and closure of the throat airway. Dr. B.V., however, opined that there was a clear nexus between the psychological and biological cause with the resultant airway and muscle collapse which results in sleep apnea. The examiner stated that people with severe stress have disruptions of their REM sleep, due to nightmares and the activation of the sympathic nervous system. The examiner further explained that the sympathic release of stress hormones can cause inflammation and metabolic unrest, cause the brain not to send proper signals to the muscles that control breathing during sleep. The examiner stated that PTSD itself causes significant stress and disruption in the body, and that veterans with PTSD are more likely to experience other health conditions, including sleep disorders. Thus, the examiner concluded that the research supports a conclusion that there was a nexus "between PTSD, stress, trauma, mood disorders and upper airway instability and resistance, and the physical basis of sleep apnea."  As such, the examiner opined that the Veteran's sleep apnea was more likely than not caused by, or aggravated by, his service-connected PTSD. 

The Veteran was afforded a VA examination and medical opinion in October 2020. At that time, the examiner noted a diagnosis of obstructive sleep apnea. The VA examiner opined that it was less likely than not that the OSA was due to or the result of the service-connected PTSD. The examiner explained that while medical literature discusses and association between PTSD and sleep apnea, PTSD has not been shown to cause sleep apnea. The examiner instead attributed the sleep apnea to the Veteran's obesity, but opined that it was not possible to determine whether his service-connected PTSD or hypothyroidism caused him to become obese. 

In weighing the etiological opinions of record, the Board first looks to the October 2020 VA opinion. While the VA examiner addressed proximate cause, the examiner did not address aggravation separately. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). It is important to note, however, that the VA examiner does concede that medical literature does suggest a relationship between PTSD and OSA. Further, the Board notes that the VA examiner failed to address the private examiner's findings that stress related to PTSD can impact upper airway instability and resistance leading to the physical basis of sleep apnea.
 medical opinion regarding secondary service connection must address causation and aggravation separately. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). It is important to note, however, that the VA examiner does concede that medical literature does suggest a relationship between PTSD and OSA. Further, the Board notes that the VA examiner failed to address the private examiner's findings that stress related to PTSD can impact upper airway instability and resistance leading to the physical basis of sleep apnea. The Board must address all theories of entitlement raised by a claimant or reasonably raised by the record. See Robinson v. Peake, 21 F.3d 545, 553 (Fed. Cir. 2008). VA must consider all lay and medical evidence of record. 38 U.S.C. § 1154 (a); 38 U.S.C. § 5107; 38 C.F.R. § 3.303. For these reasons, the Board affords the VA opinion of record limited probative value. 

In contrast, the Board notes that the positive opinion offered by the August 2020 private examiner, Dr. B.V., specifically noted a review of the Veteran's medical records and the conclusions referenced detail of the claims file and the lay statements of the Veteran and therefore are of strong probative value. Furthermore, this examiner was familiar with the medical theories involving the impacts of the Veteran's military service, as well as his service-connected PTSD on his claimed OSA. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13?Vet. App.?444, 448-9 (2000).  The examiner's opinion considered the Veteran's specific contentions, the claims file, and clinical medical evidence, before providing a positive opinion. See Nieves-Rodriguez v. Peake, 22?Vet. App.?295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). There is no evidence that Dr. B.V. was not competent or credible, and as the opinion was based on accurate facts, the Board finds that it is entitled to significant probative weight as to the etiology of the Veteran's OSA. See Nieves-Rodriguez, Id.

Thus, based upon the foregoing and resolving reasonable doubt in favor of the Veteran, in light of the August 2020 private medical opinion, the Board finds that the evidence is sufficient to find that the Veteran's sleep apnea is related to his service-connected PTSD, on a secondary basis. As such, the Board finds that service connection for the OSA on a secondary basis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102

2. Service connection for hypertension, as secondary to the service-connected mental health disorder is granted. 

The Veteran contends that his hypertension is related to his active-duty service, to include as secondary to his service-connected PTSD. See August 2020 VA Form 20-0995. For the reasons explained below, the Board finds that service-connection for hypertension is warranted on a secondary basis, via his obesity as an intermediate step. 

Turning to the evidence of record, a private medical opinion from Dr. B.V. was added to the claims file in August 2020. In that medical opinion the Veteran reported taking Klonopin and Sertraline for his PTSD from 2008 to 2019, and then being prescribed Xanax, Lexapro and Prazosin. The doctor noted that Sertraline, Xanax, and Lexapro have weight gain as a side effect. The doctor then opined that the Veteran's PTSD and its medications caused significant weight gain and obesity that contributed to the onset of his OSA and hypertension.  It was further noted that "[t]here is valid and substantial research on the physiological effects of PTSD and the body," and that "PTSD and trauma stressors have been repeatedly shown to cause and/or aggravate many medical conditions including...hypertension..."  The doctor further noted that "[h]ypothyroidism has been shown to cause fatigue, muscle weakness and weight gain." 

Dr. B.V. noted that the Veteran's current weight was 300 pounds, and he had been diagnosed with obesity. The examiner explained that while the causes
 weight gain as a side effect. The doctor then opined that the Veteran's PTSD and its medications caused significant weight gain and obesity that contributed to the onset of his OSA and hypertension.  It was further noted that "[t]here is valid and substantial research on the physiological effects of PTSD and the body," and that "PTSD and trauma stressors have been repeatedly shown to cause and/or aggravate many medical conditions including...hypertension..."  The doctor further noted that "[h]ypothyroidism has been shown to cause fatigue, muscle weakness and weight gain." 

Dr. B.V. noted that the Veteran's current weight was 300 pounds, and he had been diagnosed with obesity. The examiner explained that while the causes of essential hypertension are unknown, secondary hypertension does have known causes. The examiner explained that secondary hypertension causes can include PTSD, trauma, stress, obesity, cardiovascular disorder, lifestyle and genetics. The examiner explained that the research supports a connection between trauma stressors and hypertension, as well as between obesity and weight gain and the development of  hypertension. The examiner noted that the Veteran developed hypertension post-service, during a time of stress and weight gain. The examiner opined that the Veteran's weight gain has caused his hypertension. Also, in an August 2020 private medical opinion, Dr. S.L. opined that the Veteran's hypertension was more likely than not secondary to his PTSD, which also leads to obesity and sleep apnea which are contributors to hypertension. The examiner cited to several articles, including one which discussed a finding that soldiers with PTSD were more likely to develop high blood pressure than those without the disorder. The examiner also cited to a medical article which noted that excessive weight gain is a major cause of hypertension. 

The Veteran was afforded a VA examination and medical opinion in September 2020. At that time, the examiner noted diagnosis of hypertension. The Veteran reported that he began to experience symptoms of hypertension in 2008, after his PTSD symptoms began impacting his everyday life. The examiner opined that it was less likely than not that the claimed hypertension was related to the PTSD. The examiner's rationale that there was no medical evidence that the claimed hypertension was caused by his PTSD. 

In an October 2020 VA medical opinion, the Board notes that the examiner opined that the Veteran's obesity was a substantial factor in causing or aggravating his hypertension. The examiner explained that obesity was a risk factor for the development of hypertension, and it was more likely than not that the Veteran's hypertension was aggravated by his obesity. The examiner stated, however, that it was not possible to determine if his obesity caused his hypertension. The examiner opined that it was not possible to determine whether the Veteran's PTSD or hypothyroidism caused him to become obese, or if the hypertension would not have occurred but for the obesity. The examiner opined that the Veteran's hypertension was likely multifactorial, secondary to his genetic predisposition, activity level, diet, obesity and other co-morbidities.

In weighing the medical opinions of record, the Board first looks to the September 2020 VA opinion. While the examiner provided a negative opinion for secondary service connection, the Board however finds that the examiner provided a generally conclusory statement and failed to provide sufficient rationale for the negative nexus opinion, including discussing the specific facts of the Veteran's case. A general conclusory statement is not adequate for a rationale. The explanation should contain clear conclusions and a supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr v. Nicholson, 21 Vet. App. 303 (2007). Further, while the examiner addressed proximate cause, the examiner failed to address aggravation separately. For these reasons, the Board affords this opinion limited probative value.

The Board next notes that the VA examiner who rendered the October 2020 opinion, and the August 2020 private examiner were both competent to opine as to the etiology of the Veteran's hypertension. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159 (a)(1). Both examiners opined that the Veteran's obesity was a substantial factor in contributing to his hypertension. However, while the private examiner attributed the Veteran's obesity to his service-connected PTSD, the VA examiner opined that it was not possible to determine if the Veteran's PTSD or hypothyroidism caused him to become obese. The VA and private opinions were rendered after an evaluation of the record, in light of the Veteran's history and specific contentions and with consideration of medical principles by licensed medical professionals.

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
 statements, or opinions. 38 C.F.R. § 3.159 (a)(1). Both examiners opined that the Veteran's obesity was a substantial factor in contributing to his hypertension. However, while the private examiner attributed the Veteran's obesity to his service-connected PTSD, the VA examiner opined that it was not possible to determine if the Veteran's PTSD or hypothyroidism caused him to become obese. The VA and private opinions were rendered after an evaluation of the record, in light of the Veteran's history and specific contentions and with consideration of medical principles by licensed medical professionals.

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 veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

Based on the foregoing, the Board finds that the Veteran's claim of service connection for his hypertension as secondary to his service-connected PTSD, via his obesity as an intermediate step, is granted. The test in this theory of service connection is whether there is some evidence in the record that draws an association or suggests a relationship between the Veteran's obesity, or weight gain resulting in obesity, and a service-connected disability. Garner v. Tran, 33 Vet. App. 241, 246-47 (2021); see Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020); VAOPGCPREC 1-2017.

Garner provided a list of six non-exhaustive considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step: (1) mobility limitations or reduced physical activity as a result of a service-connected physical disability; (2) reduced physical activity or inability to follow a course of exercise or diet as a result of service-connected mental disability; (3) side effects of medication where the medication is prescribed for a service-connected disability; (4) treatise evidence suggesting a connection between all or some combination of obesity, service-connected disability, and the claimed condition; (5) lay statements by a veteran attributing weight gain or obesity to the service-connected disability; and (6) statements by treating physicians or medical examiners attributing weight gain or obesity to the service-connected disability. Here, the August 2020 private examiner noted multiple Garner factors in the opinion in favor of secondary service connection via an intermediate finding of obesity. The examiner explained that the research supports a connection between trauma stressors and hypertension, as well as between obesity and weight gain and the development of hypertension. The doctor also opined that the Veteran's PTSD and its medications caused significant weight gain and obesity that contributed to the onset of his hypertension.  

The Board thus finds that the approximate balance of the evidence demonstrates, at a minimum, that the Veteran's PTSD caused the Veteran to become obese, and that his obesity was a substantial factor, in the development of his hypertension. A disability can be service-connected on a secondary basis if proximately due to, or the result of, a service-connected condition. See 38 C.F.R. § 3.310(a). In order to establish entitlement to service connection on a secondary basis, there must be (1) a current disability; (2) a service-connected disability; and (3) a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran is already service connected for PTSD, and the Board finds as well that service connection for hypertension is warranted for the Veteran on a theory of secondary service connection. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995).

Based on the above, the Board finds that the evidence of record is sufficient to find that that the Veteran's claimed hypertension was incurred due to service, on a basis that obesity may serve as an intermediate step between a service-connected disability of the PTSD and a condition claimed on a basis of secondary service connection discussed above. Garner, 33 Vet. App. at 246-47; see Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020); VAOPGCPREC 1-2017. For these reasons, the Board finds that an approximate balance of the evidence is in favor of the claim of service connection for hypertension, and the claim must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th
 serve as an intermediate step between a service-connected disability of the PTSD and a condition claimed on a basis of secondary service connection discussed above. Garner, 33 Vet. App. at 246-47; see Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020); VAOPGCPREC 1-2017. For these reasons, the Board finds that an approximate balance of the evidence is in favor of the claim of service connection for hypertension, and the claim must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

 

Ardie A. Bland

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Nettey, Counsel

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.