SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, an Army Veteran who served from June 1969 to April 1971, appeals the denial of service connection for obstructive sleep apnea as secondary to his service-connected diabetes mellitus, type II. The case has a complex procedural history, with multiple remands from the Board of Veteran's Appeals (Board) to the agency of original jurisdiction (AOJ) for adequate medical opinions regarding the sleep apnea claim. The Veteran initially requested a hearing but later withdrew it. The Board previously granted service connection for hypertension prior to the PACT Act. The primary issue before the Board is the secondary service connection for obstructive sleep apnea. The Veteran has a current diagnosis of obstructive sleep apnea and is service-connected for diabetes mellitus, type II, with related complications including obesity and diabetic neuropathy. The VA examiner noted a bidirectional link between sleep apnea and diabetes, where each can worsen the other, though a subsequent addendum attempted to disavow this link without providing a clear rationale. The Board found the addendum inadequate. Considering the existing service connection for diabetes and its complications, and the repeated failure to obtain an adequate opinion, the Board found the evidence in approximate balance. Applying the benefit of the doubt, service connection for obstructive sleep apnea as secondary to diabetes mellitus, type II, was granted.

Rationale

Veteran has current diagnosis of obstructive sleep apnea.; Veteran is service-connected for diabetes mellitus, type II, with complications including obesity and diabetic neuropathy.; VA examiner noted bidirectional link between OSA and diabetes.; Subsequent VA addendum was inadequate.; Evidence for and against secondary connection found in approximate balance.

Full Decision Text

Citation Nr: 26004598
Decision Date: 04/16/26	Archive Date: 04/16/26

DOCKET NO. 19-35 745
DATE: April 16, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea as secondary to service-connected diabetes mellitus, type II, is granted.

FINDING OF FACT

Applying benefit of the doubt, the Veteran's obstructive sleep apnea is secondary to his service-connected diabetes mellitus, type II.

CONCLUSION OF LAW

The criteria for service connection for low back condition have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from June 1969 to April 1971.

This matter comes before the Board of Veteran's Appeals (Board) on appeal of a December 2017 rating decision issued by a regional office (hereinafter agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). In his November 2019 Form 9 appeal, the Veteran requested a hearing before a Veterans Law Judge, which was scheduled for September 2022. However, in August 2022 written correspondence his representative indicated his desire to withdraw the hearing request.

In the July 2023 Board decision, the Board granted the Veteran's claim for service connection to hypertension based on the presumption created by the PACT Act and remanded the claim for adjudication of the period on appeal prior to the effective date of the PACT Act. Furthermore, the Board remanded the claim of service connection for a sleep disorder in order to afford the Veteran a VA examination as to the nature and etiology of the claimed disorder.

In the February 2025 Board decision, the Board remanded the claims of service connection for hypertension prior to the passage of the PACT Act and service connection for sleep apnea to afford the Veteran adequate VA medical opinions regarding the claimed disabilities.

In the October 2025 Board decision, the Board granted service connection for hypertension prior to the passage of the PACT Act and remanded the claim of service connection for sleep apnea to once again attempt to provide the Veteran an adequate VA medical opinion regarding his obstructive sleep apnea.

Having afforded the Veteran VA medical opinions regarding the Veteran's sleep apnea, the AOJ continued the denial of the claim in the February 2026 Supplemental Statement of the Case (SSOC) and returned the matter to the Board for further adjudication.

1. Entitlement to service connection for obstructive sleep apnea as secondary to service-connected diabetes mellitus, type II, is granted.

"Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected." 38 C.F.R. § 3.310(a). Secondary service connection is warranted where a non-service-connected disability would have been less severe "but-for" a service connected disability, either because there is an etiological link (to include worsening functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability. Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995).

The Veteran has a current diagnosis of obstructive sleep apnea. See December 2025 Disability Benefits Questionnaire. In the December 2025 VA medical opinion the VA examiner explained that "Research confirms bidirectional link not causal between Obstructive Sleep Apnea (OSA) and Diabetes, where OSA worsens blood sugar control (insulin resistance) and diabetes can worsen OSA, often driven by shared factors like obesity, but also unique mechanisms like diabetic neuropathy affecting breathing." See December 2025 C&P Examination. In a February 2026 addendum to the December 2025 VA medical opinion, the author of the prior opinion requested the Board to disregard the February 2026 opinion writing that "No medical literature currently shows that the service-connected diabetes mellitus II with erectile dysfunction aggravated the claimed condition of sleep apnea." See February 2026 C&P Examination.

Medical opinions "must be read as a whole" to determine the examiner's rationale. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). Although the
en OSA, often driven by shared factors like obesity, but also unique mechanisms like diabetic neuropathy affecting breathing." See December 2025 C&P Examination. In a February 2026 addendum to the December 2025 VA medical opinion, the author of the prior opinion requested the Board to disregard the February 2026 opinion writing that "No medical literature currently shows that the service-connected diabetes mellitus II with erectile dysfunction aggravated the claimed condition of sleep apnea." See February 2026 C&P Examination.

Medical opinions "must be read as a whole" to determine the examiner's rationale. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). Although the VA medical examiner could have explained why their earlier opinion was erroneous, they did not. As the February 2025 addendum did not provide a rationale as to why the earlier opinion written by the same VA examiner was erroneous, the February 2025 addendum is inadequate and afforded no probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-02 (2008).

Although there is no medical opinion of record which addresses whether the "bidirectional link" between obstructive sleep apnea and diabetes mellitus was actually present in the Veteran's case, the Board cannot ignore that the Veteran is also service-connected for diabetic neuropathy of the bilateral upper and lower extremities and April 2025 VA Treatment records indicate that the Veteran has obesity-both obesity and diabetic neuropathy were identified as symptoms related to diabetes which could aggravate obstructive sleep apnea. Considering the foregoing, and considering the repeated inability to provide an adequate medical opinion, the Board finds that the evidence for and against a finding that the Veteran's obstructive sleep apnea was aggravated by his service-connected diabetes mellitus, type II, is in approximate balance. As such, service connection for obstructive sleep apnea as secondary to diabetes mellitus, type II, is granted. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

 

 

T. MAINELLI

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Biggs, Andrew J.

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.