SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, a Veteran who served from November 1987 to December 1995, appeals the denial of service connection for obstructive sleep apnea (OSA). The Veteran claims OSA developed secondary to his service-connected right knee disability, with obesity as an intermediate step. The Board reviewed three VA examinations concerning this claim. The November 2023 examination found OSA not directly related to service, noting the lack of in-service complaints and suggesting post-service factors as the most likely etiology, despite the Veteran's knee injury. The December 2023 examination found OSA unrelated to the knee disability, citing separate medical mechanisms and lack of supporting literature. The July 2024 examination also found OSA unrelated to the knee disability or obesity, emphasizing multifactorial causes of OSA and the passage of time since service. The Veteran contended the VA opinions were inadequate, particularly regarding the knee's impact on mobility and weight gain. The Board found the VA opinions adequate, noting they considered the Veteran's limited mobility but found other weight management options existed. The Board also reviewed a medical article suggesting an association between knee arthritis and OSA but afforded it less weight than the specific VA opinions. Finding the evidence weighed against the claim, the Board denied service connection for OSA.

Rationale

November 2023 VA exam found OSA not directly related to service; service treatment records were silent for complaints/treatment of OSA.; Examiner noted Veteran's assertion of weight gain from knee injury causing OSA but cited other weight management options.; December 2023 VA exam found OSA unrelated to knee disability due to separate medical mechanisms and lack of supporting literature.; July 2024 VA exam found OSA unrelated to knee disability or obesity, citing multifactorial causes of OSA and passage of time since service.; Board found VA opinions adequate, considering Veteran's contentions but ultimately finding no basis for nexus.

Full Decision Text

Citation Nr: A26011024
Decision Date: 02/05/26	Archive Date: 02/05/26

DOCKET NO. 250915-590098
DATE: February 5, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea is denied.

FINDING OF FACT

The evidence persuasively weighs against a finding that the Veteran's obstructive sleep apnea was caused or aggravated by service or a service-connected disability, to include with obesity as an intermediate step.

CONCLUSION OF LAW

The criteria for entitlement to service connection for obstructive sleep apnea have not been met.  38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.30, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from November 1987 to December 1995.  The Board of Veterans' Appeals (Board) thanks the Veteran for his service to our country.

In the September 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

In January 2024, the appellant submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a January 2024 rating decision. In a May 2024 higher level review rating decision, a duty to assist error was identified for the Veteran's claim for OSA, prompting a special review.  In October 2024, the agency of original jurisdiction (AOJ) issued the rating decision on appeal, which considered the evidence of record at the time of that rating decision. Therefore, because a duty to assist error was identified during the higher-level review, the Board may only consider the evidence of record at the time of the October 2024 rating decision, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303.  If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review 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. 

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.

Generally, the Board may not decide an appeal before the deadline for requesting an AMA docket switch has elapsed. Williams v. McDonough, 37 Vet. App. 305 (2024). 38 C.F.R. § 20.202(c)(2) allows appellants to switch AMA dockets by completing and submitting a new VA Form 10182 within 60 days from when the Board receives the original VA Form 10182, or one year from the date the AOJ mails notice of the decision on appeal, whichever is later, unless (1) an appellant has already submitted evidence or testimony as described in 38 C.F.R. §§ 20.302 and 20.303, or (2) the appellant or representative has requested a waiver of the ability to request to switch dockets during this timeframe.  However, in the September 2025 correspondence attached to the VA Form 10182, the Veteran's attorney submitted medical literature in support of the Veteran's claim.  As the Veteran has submitted evidence within the evidentiary window, the Veteran may no longer switch dockets and the Board will proceed with adjudication of the claim.

Entitlement to service connection for obstructive sleep apnea as secondary to the Veteran's service-connected right knee disability, with obesity as an intermediate step,

The Veteran contends that due to his service-connected right knee disability, he developed obesity and, as a result, developed obstructive sleep apnea.  See September 2025 and March 2023 Correspondence.

Generally, to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury;
  As the Veteran has submitted evidence within the evidentiary window, the Veteran may no longer switch dockets and the Board will proceed with adjudication of the claim.

Entitlement to service connection for obstructive sleep apnea as secondary to the Veteran's service-connected right knee disability, with obesity as an intermediate step,

The Veteran contends that due to his service-connected right knee disability, he developed obesity and, as a result, developed obstructive sleep apnea.  See September 2025 and March 2023 Correspondence.

Generally, to establish service connection for a claimed disorder, the following must be shown: (1) the existence of a present disability; (2) 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.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability.  See 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability.  Id.  Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.

While obesity itself is not a disability for VA compensation purposes, it may constitute an "intermediate step" for service connection on a secondary basis if the evidence shows (1) the service-connected disability caused the Veteran to become obese or aggravated obesity; (2) obesity caused or aggravated by the service-connected disability was a substantial factor in causing the nonservice-connected disorder; and (3) the nonservice-connected disorder would not have occurred but for obesity caused by service-connected disability.  38 C.F.R. § 3.310; VAOPGCPREC 1-2017 (Jan. 6, 2017).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with the veteran prevailing in either event, or whether the evidence weighs persuasively against the claim, in which case the claim is denied.  Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

As an initial matter, the Board notes that the AOJ has made a favorable finding in the October 2024 rating decision on appeal that the Veteran has been diagnosed with a disability as November 2023 VA examination noted a diagnosis of OSA and the Veteran is service-connected for the primary disability-a right knee disability.  Thus, the remaining question for the Board is one of nexus.  To this element, the Veteran was afforded three VA examinations.

In November 2023 the Veteran was afforded a VA examination.  Following a review of the Veteran's claims file and an in-person examination, the examiner found the Veteran's obstructive sleep apnea (OSA) was not directly related to service as the Veteran's service treatment records were silent for complaints and treatment of OSA.  The examiner noted the Veteran's assertion that weight gain from his knee injury, which prevented him from full mobility, resulted in his OSA; however, the examiner noted that recovery for a patellar tear takes only 6 months and there are other mechanisms available for maintaining a healthy weight such as portion control, healthy diet, low impact exercise, passive exercise, etc.  The examiner also stated that the Veteran was discharged in 1995, but his OSA was not diagnosed until 2013 and without chronicity of complaints or treatment during or after service, a post-service event, illness, or injury is the most likely etiology.

The Board assigns the November 2023 medical opinion high probative value.  The examiner considered the specific circumstances of the Veteran's disabilities and statements in providing a
 from his knee injury, which prevented him from full mobility, resulted in his OSA; however, the examiner noted that recovery for a patellar tear takes only 6 months and there are other mechanisms available for maintaining a healthy weight such as portion control, healthy diet, low impact exercise, passive exercise, etc.  The examiner also stated that the Veteran was discharged in 1995, but his OSA was not diagnosed until 2013 and without chronicity of complaints or treatment during or after service, a post-service event, illness, or injury is the most likely etiology.

The Board assigns the November 2023 medical opinion high probative value.  The examiner considered the specific circumstances of the Veteran's disabilities and statements in providing a well-reasoned rationale to support the ultimate conclusion reached following a review of the Veteran's claims file and in-person examination.  Additionally, the examiner consulted relevant medical literature regarding patellar tears and provided examples of mechanisms which, despite the limitations of the Veteran's knee disability, would have maintained the Veteran's weight.

In December 2023, the Veteran was afforded an additional medical examination.  The examiner found the Veteran's OSA to be unrelated to his right knee disability.  The examiner reasoned that this is because the two conditions are not medically related as they are separate entities, since OSA is caused by airway obstruction during sleep and the Veteran's knee disability is caused by an orthopedic condition.  Additionally, the examiner noted that a review of the medical literature also did not support an association. 

The Board assigns high probative weight to the December 2023 medical opinion.  The examiner reviewed the Veteran's records, consulted medical literature, and provided a well-reasoned rationale, which considered the specific facts of the Veteran's conditions, to support the ultimate conclusion reached.

In July 2024, the Veteran was afforded a third VA examination.  Following a review of the Veteran's records, the examiner found that the Veteran's OSA to be unrelated to his service-connected knee disability because the two conditions are not medically related.  The examiner also found that the Veteran's service-connected right knee disability did not aggravate the Veteran's OSA because the conditions are anatomically and physiologically separate, affecting different systems of the body.  The examiner noted OSA to involve upper airway obstruction during sleep, which is influenced by unrelated factors and that the Veteran's knee surgery would only cause local complications to the joint.  The examiner also found that the Veteran's claim that his right knee disability was the sole cause for his obesity lacked substantiation based on the medical literature reviewed and medical literature also lacks sufficient evidence to establish a direct relationship between weight gain and sleep apnea because the causes of sleep apnea are multifactoral, and it is possible to have OSA without being obese.  The examiner went on to reason that obesity a complex condition, with contributing factors to include genetics, stress, age, and physical activity, that cannot be exclusively attributed to the Veteran's right knee disability.  The examiner went on to note that musculoskeletal discomfort can disrupt sleep patterns, but it does not cause airway obstruction and that while obesity is a modifiable factor that can reduce the risk of OSA, its presence does not automatically imply a causal relationship.  The examiner concluded the opinion my stating that over twenty years have passed since the Veteran's discharge and in that time multiple aspects of his lifestyle, diet, and physical activities could have been adjusted that would have prevented his obesity; thus, his gradual weight gain could not have been solely attributed to his medical condition.

The Board affords high probative value to the July 2024 VA medical opinion as well.  The opinion considered the specific circumstances of the Veteran's conditions and his contention, reviewed relevant medical literature, and provided a well-reasoned rationale as to why the two conditions are unrelated to one another.

The Board notes that the Veteran contends that the VA medical opinions of record are inadequate.  See September 2025 Correspondence.  Specifically, the Veteran contends that the 2023 VA examiner discounted the Veteran's intermediate step theory by stating that obesity is largely due to excess calories and too little movement without considering the Veteran's impaired ability to exercise given the knee condition.  The Veteran also contends that the 2024 VA examiner gave no specific consideration to this theory and merely concluded that the knee "does not necessarily aggravate" sleep apnea because the conditions are "distinct."   The Veteran argues that the opinion does not fully explain why obesity and the knee are unrelated to the onset of sleep apnea as it relates to his inability to move sufficiently to avoid obesity.  The Board finds, however, that the opinions of record are adequate and do address the contentions outlined.  The November and December 2023 medical opinions did consider the Veteran's limited mobility as a result of his right knee disability but noted that there were other options
 little movement without considering the Veteran's impaired ability to exercise given the knee condition.  The Veteran also contends that the 2024 VA examiner gave no specific consideration to this theory and merely concluded that the knee "does not necessarily aggravate" sleep apnea because the conditions are "distinct."   The Veteran argues that the opinion does not fully explain why obesity and the knee are unrelated to the onset of sleep apnea as it relates to his inability to move sufficiently to avoid obesity.  The Board finds, however, that the opinions of record are adequate and do address the contentions outlined.  The November and December 2023 medical opinions did consider the Veteran's limited mobility as a result of his right knee disability but noted that there were other options for movement which would not have involved the Veteran's knee, such as passive exercise, or options which do not involve movement at all, such as consuming smaller portions, which would have averted the Veteran's obesity.  Additionally, as the argument pertains to the July 2024 medical opinion giving no specific consideration to the Veteran's argument that his right knee disability contributed to his OSA, the Board finds that the July 2024 medical opinion did give such consideration; however, the examiner did note that they are separate mechanisms of illness and given the circumstances of onset of each condition as well as the relevant medical literature, there was no basis to establish that nexus in this case.

The Board also notes that the Veteran submitted a medical article titled "Prevalence of and Characteristics Associated with Insomnia and Obstructive Sleep Apnea Among Veterans with Knee and Hip Arthritis" in September 2025.  This article found that insomnia and obstructive sleep apnea symptoms were very common among Veterans with osteoarthritis.  The Board acknowledges that the article suggests an association to support of the Veteran's contention, however, the other evidence of record, namely the three above-discussed VA medical opinions, are attributed more probative weight because the opinions provided are specific to the Veteran's circumstances.

As such, the Board finds that the evidence of record is not in approximate balance; therefore, the benefit of the doubt rule is not for application, and the claim must be denied.  Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

 

M. C. GRAHAM

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Makarenko, Associate 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.