SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran, who served in the U.S. Navy from November 1985 to November 1989, with subsequent Reserve and National Guard active duty periods, appeals the denial of service connection for obstructive sleep apnea (OSA), GERD, and hypertension. The veteran claimed OSA was related to service or secondary to PTSD, GERD was secondary to PTSD, and hypertension was secondary to PTSD. The Board reviewed evidence from the time of the AOJ decisions, noting that any later-submitted evidence would require a Supplemental Claim. For OSA, the Board found the evidence weighed against an in-service onset or relation, citing the lack of contemporaneous complaints in service treatment records and post-deployment assessments, and the correlation between symptom onset and post-service weight gain. VA examiners opined OSA was less likely than not caused by service or TERAs, attributing it to non-service-related risk factors like obesity. For GERD and hypertension, the Board found the evidence weighed against a secondary connection to PTSD, citing VA examiner opinions that these conditions are medically unrelated to PTSD and that hypertension was not aggravated beyond its natural progression by service or PTSD, with risk factors like obesity and family history being more consistent etiologies. The Board assigned significant weight to the VA examiner opinions, finding them persuasive and consistent with the record, and concluded the evidence persuasively weighed against service connection for all claimed conditions. The benefit of the doubt doctrine was not applied as the evidence favored one side.

Rationale

Service treatment records do not document complaints, treatment, or diagnosis related to sleep apnea during service.; Contradictory post-deployment health assessments denied sleep issues.; Examiner opined OSA less likely than not caused by service, citing obesity and lack of TERA link.

Full Decision Text

Citation Nr: A26016382
Decision Date: 02/24/26	Archive Date: 02/24/26

DOCKET NO. 250102-505689
DATE: February 24, 2026

ORDER

Service connection for obstructive sleep apnea, as directly related to service and/or as secondary to posttraumatic stress disorder (PTSD), is denied.

Service connection for gastroesophageal reflux disorder (GERD), as secondary to PTSD, is denied.

Service connection for hypertension, as secondary to PTSD, is denied. 

FINDINGS OF FACT

1. The evidence of record persuasively weighs against finding that the Veteran's obstructive sleep apnea began during active service, is otherwise related to an in-service injury or disease, or is secondary to his service-connected PTSD.

2. The evidence of record persuasively weighs against finding that the Veteran's GERD disability is secondary to service-connected PTSD.

3. The evidence of record persuasively weighs against finding that the Veteran's hypertension disability is secondary to service-connected PTSD.

CONCLUSIONS OF LAW

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

3. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Navy from November 1985 to November 1989. He was thereafter a member of the Reserve and National Guard, during which he had additional periods of active duty, including from September 2008 to February 2009,  May 2010 to September 2010, April 2012 to September 2012, July 2016 to November 2016, July 2018 to November 2018, November 2020 to April 2021, and from September 2023 to December 2023.

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

Therefore, the Board may only consider the evidence of record at the time of the two December 2024 agency of original jurisdiction (AOJ) decisions on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decisions on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 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 claims, 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

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(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." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

A Veteran may establish service connection on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) requires evidence of three elements: (1) evidence of a current disability that is not service-connected
 or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

A Veteran may establish service connection on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) requires evidence of three elements: (1) evidence of a current disability that is not service-connected; (2) evidence of a service-connected disability; and (3) evidence of nexus establishing a connection between the service-connected disability and the current disability. 38 C.F.R. § 3.310.

Service connection for obstructive sleep apnea.

The Veteran contends that his OSA began during his period of active service in 2010, during or following his deployment in Iraq in 2010. See May 2020 VA Sleep Apnea Examination; June 2025 Appellate Brief.

The Veteran's service department records indicate that he participated in multiple toxic exposure risk activities (TERAs) during service, having served at least 30 days at Camp Lejeune prior to December 31, 1987, and serving tours of duty in Iraq and Qatar after September 11, 2001. He asserts that prior to deployment, he had no issues with sleeping, but that upon his return, he began experiencing snoring and daytime fatigue. 

The Veteran's spouse submitted a statement stating that his sleeping habits changed after his return from Iraq. She stated that the Veteran would snore loudly and gasp for air. She also stated that he was constantly aware at night and it was hard for him to stay asleep, creating daytime fatigue. See March 2020 Statement from Spouse.

The AOJ made favorable findings that the Veteran has been diagnosed with a sleep apnea disability, and that participation in a TERA is conceded based on the Veteran's service in Camp Lejeune and Southwest Asia. These are favorable findings, and binding on the Board, absent clear and unmistakable error. See 38 C.F.R. § 3.104(c).

The question for the Board is whether the Veteran's sleep apnea disability began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of sleep apnea, the evidence of record persuasively weighs against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease.  

Service treatment records do not document complaints, treatment, or diagnosis related to sleep apnea during service.

In March 2014, the Veteran reported not sleeping well since his 2010 deployment to Iraq. This contradicts August 2010 and April 2013 post deployment health assessments, during which the Veteran denied issues with sleep. Further, an October 2014 obstructive sleep apnea risk assessment evaluated the Veteran as low risk for obstructive sleep apnea.  

After reviewing the claims file, the May 2020 examiner opined that the condition was less likely than not caused by service. Although the Veteran and his spouse reported onset of sleep apnea symptoms during or shortly after deployment to Iraq, the examiner found that contemporaneous service records contradict those statements. Post-deployment health assessments in August and December 2010 reflect that the Veteran affirmatively denied problems sleeping, feeling tired after sleeping, or developing any medical conditions during deployment. A subsequent April 2013 assessment was silent for sleep related complaints. The examiner noted that there were no documented sleep-related complaints until 2017, approximately ten years after deployment. Medical records beginning in February 2017 documented complaints of poor sleep, insomnia, snoring, and daytime fatigue, and a January 2018 sleep study confirmed moderate sleep apnea. The examiner further observed that the Veteran's body mass index increased over time and was highest around the period when sleep apnea symptoms were first clinically documented and diagnosed. The examiner concluded that the timing of symptoms onset and diagnosis was more consistent with the Veteran's post-service weight gain rather than an in-service origin. 

After review of the claims file and consideration of the Veteran's total potential exposure during all applicable military deployments, the April 2024 examiner concluded that the conditions is less likely than not caused by or the result of TERA. The examiner opined that the Veteran's condition was more likely attributed to non-toxic risk factors, rather than any synergistic or cumulative effect of toxic exposure during service. Specifically, the examiner cited medical literature from the Mayo Clinic identifying common etiologies for obstructive sleep apnea
 time and was highest around the period when sleep apnea symptoms were first clinically documented and diagnosed. The examiner concluded that the timing of symptoms onset and diagnosis was more consistent with the Veteran's post-service weight gain rather than an in-service origin. 

After review of the claims file and consideration of the Veteran's total potential exposure during all applicable military deployments, the April 2024 examiner concluded that the conditions is less likely than not caused by or the result of TERA. The examiner opined that the Veteran's condition was more likely attributed to non-toxic risk factors, rather than any synergistic or cumulative effect of toxic exposure during service. Specifically, the examiner cited medical literature from the Mayo Clinic identifying common etiologies for obstructive sleep apnea, including obesity, increased neck circumference, being male, advancing age, family history, alcohol or sedative use, smoking, nasal congestion, and underlying medical conditions such as hypertension, diabetes, congestive heart failure, and chronic lung disease. Review of the Veteran's treatment records shows notations for the identified risk factors of abdomen obese with a BMI of 32.6, a neck circumference of 15-1/2 inches, male, and hypertension. See January 2018 and February 2019 VA Treatment Records. The examiner found no medical evidence demonstrating that TERAs were a causative factor in the Veteran's claimed condition and concluded that sleep apnea is more consistent with non-service related risk factors. 

While the Veteran and spouse are competent to report sleep problems, the Board finds that the statements regarding onset during service are outweighed by contemporaneous medical records and inconsistency with other evidence in the record, which reflect repeated denials of sleep-related symptoms and do not show documented, objective findings of a sleep condition. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).

Based on the Veteran's repeated denials of problems on post-deployment assessments, the absence of contemporaneous documented sleep apnea symptoms, and the correlation between symptom onset and increased BMI, the Board finds that the evidence is persuasively against a finding that obstructive sleep apnea was incurred in or caused by service, to include TERAs. As the reviewable evidence of record in this case does not relate the Veteran's sleep apnea condition to his active service, the criteria for entitlement to service connection for this condition are not met, and the appeal must be denied.

In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine.  As the evidence persuasively favors one side or the other, the doctrine is not for application.  See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc); 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Service connection for GERD.

The Veteran seeks service connection for GERD secondary to PTSD.  See October 2020 VA Form 21-526EZ, Fully Developed Claim; see also June 2021 Appellate Brief and June 2025 Appellate Brief. The Veteran has not contended entitlement to direct service connection, and this theory of entitlement is not otherwise raised by any of the evidence of record. Thus, the Board will not address direct service connection further. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

The AOJ made favorable findings that the Veteran has a primary PTSD disability that is service-connected, the Veteran has a current GERD diagnosis, and participation in a TERA is conceded since the Veteran served at Camp Lejeune and in Southwest Asia. These are favorable findings, and binding on the Board, absent clear and unmistakable error. See 38 C.F.R. § 3.104(c).

The question for the Board is whether the Veteran has a current disability that is at least as likely as not related to a service-connected disability. The Board concludes that, while the Veteran has a diagnosis of GERD, the evidence of record persuasively weighs against finding that it is secondary to a service-connected disability.  

The Veteran denied frequent indigestion and heartburn in post deployment health assessments. See August 2010 and July 2012 service treatment records.

The Veteran was afforded a VA examination in November 2020. The examiner opined that the Veteran's GERD was less likely than not due to or the result of his PTSD condition, explaining that the conditions are not medically related as GERD is caused by frequent acid reflux, explaining that when one swallows, a circular band of muscle around the bottom of your esophagus (lower
 to a service-connected disability. The Board concludes that, while the Veteran has a diagnosis of GERD, the evidence of record persuasively weighs against finding that it is secondary to a service-connected disability.  

The Veteran denied frequent indigestion and heartburn in post deployment health assessments. See August 2010 and July 2012 service treatment records.

The Veteran was afforded a VA examination in November 2020. The examiner opined that the Veteran's GERD was less likely than not due to or the result of his PTSD condition, explaining that the conditions are not medically related as GERD is caused by frequent acid reflux, explaining that when one swallows, a circular band of muscle around the bottom of your esophagus (lower esophageal sphincter) relaxes to allow food and liquid to flow into the stomach. The sphincter closes, but if the sphincter relaxes abnormally or weakens, stomach acid can flow back up into the esophagus. This constant backwash of acid irritates the lining of the esophagus, often causing it to become inflamed. The examiner concluded that a thorough review of medical literature failed to demonstrate a causal relationship between the Veteran's GERD and PTSD.  

The April 2024 examiner also opined that the Veteran's claimed GERD is less likely than not due to or aggravated by his service-connected PTSD, including TERAs. The examiner explained that GERD and PTSD are separate and unrelated medical conditions and that there is no causal relationship between the conditions. The examiner explained that a baseline of severity could not be established, as the medical evidence was insufficient to determine the severity of the condition prior to any claimed aggravation. Regardless of the absence of a baseline, the examiner further opined that PTSD did not aggravate the Veteran's condition and referenced medical literature identifying common risk factors and aggravating influences for GERD, including obesity, hiatal hernia, delayed gastric emptying, connective tissue disorders, smoking, dietary habits, alcohol or caffeine intake, and certain medications.  As stated above, the Veteran's treatment files have identified an obesity condition. The examiner found no evidence that PTSD caused or worsened the Veteran's GERD. 

Upon review of the claims file, the examiner also determined that the Veteran's GERD presents a clear disease with a clear and specific diagnosis and etiology, rather than an undiagnosed illness or a medical unexplained chronic multi symptoms illness. 

The Board assigns significant probative weight to the VA examiner's opinions, as they were rendered by qualified examiners who reviewed the claims file, including lay statements, and supported opinions with sufficient rationale. The examiners explained that medical literature did not support that PTSD caused or aggravated the Veteran's GERD and further identified risk factors. Based on the examiner's medical opinions, the Veteran's PTSD did not cause or worsen the Veteran's GERD. The Board finds the opinion persuasive, as they are consistent with the medical evidence of record, which does not show worsening attributable to the service-connected PTSD disability. 

While the Veteran is competent to report observable symptoms, the question of whether GERD is etiologically related to PTSD is a complex medical determination that requires specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the Board affords greater probative weight to the April 2024 medical opinion than to the Veteran's lay assertions. 

Based on the foregoing, the Board concludes that the evidence of record persuasively weights against a finding that the Veteran's GERD was caused or aggravated by a service-connected PTSD disability. As the reviewable evidence of record in this case does not relate the Veteran's GERD condition to his PTSD, the criteria for entitlement to service connection for this condition are not met, and the appeal is denied. In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine.  As the evidence persuasively favors one side or the other, the doctrine is not for application.  See Lynch, supra; 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Service connection for hypertension.

The Veteran seeks service connection for hypertension secondary to PTSD. See June 2021 Appellate Brief; see also June 2025 Appellate Brief.

The AOJ made favorable findings that the Veteran has been diagnosed with a primary PTSD disability that is service-connected, the Veteran had elevated blood pressure in 1993, and participation in a TERA is conceded since the Veteran served in Camp Lejeune and Southwest Asia. These are favorable findings, and binding on the Board, absent clear and unmistakable error. See 38 C.F.R. § 3.104(c). 

The question for the Board is whether the Veteran has a current disability that began during service
.F.R. § 3.102.

Service connection for hypertension.

The Veteran seeks service connection for hypertension secondary to PTSD. See June 2021 Appellate Brief; see also June 2025 Appellate Brief.

The AOJ made favorable findings that the Veteran has been diagnosed with a primary PTSD disability that is service-connected, the Veteran had elevated blood pressure in 1993, and participation in a TERA is conceded since the Veteran served in Camp Lejeune and Southwest Asia. These are favorable findings, and binding on the Board, absent clear and unmistakable error. See 38 C.F.R. § 3.104(c). 

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of hypertension, the evidence of record persuasively weighs against finding that it is caused by or aggravated by PTSD. 

First, the Board recognizes that the Veteran was first noted to have high blood pressure in 1993, more than 1 year after the Veteran's period of active duty ended in November 1989 but before his mobilization beginning in September 2008. Thus, this existed prior to the period of active duty service beginning in September 2008. To that end, the December 2020 and April 2024 VA examiners opined that the Veteran's hypertension was clearly and unmistakably not aggravated beyond its natural progression by active service. The examiners stated that while temporary fluctuations in blood pressure may occur, there was no permanent worsening attributable to service or a service-connected disability. The examiners explained that medical literature does not support aggravation of preexisting hypertension due to military service. Additionally, the Veteran reported that his hypertension began after service, which further weighs against a finding of in-service aggravation. Additionally, the examiners found no causal or aggravating relationship between hypertension and PTSD. A baseline of severity could not be established due to insufficient medical evidence. 

Regardless, the examiners concluded that the Veteran's hypertension was less likely than not aggravated beyond its natural progression by service-connected PTSD and cited well established risk factors for hypertension, including race, age, family history, obesity, physical inactivity, tobacco use, dietary factors, alcohol use, stress, and chronic medical conditions. Review of the Veteran's treatment records shows notations for the identified risk factors of obesity with a BMI of 32.6, and a family history of hypertension. See June 2013, January 2018 and February 2019 VA Treatment Records. The Veteran's hypertension was opined to be more consistent with these non-service related factors.

The Board assigns significant probative weight to the December 2020 and April 2024 VA medical opinions as the examiners reviewed the claims file, considered the Veteran's lay statements, and provided sufficient rationale supported by medical literature. Both examiners concluded that the Veteran's hypertension clearly and unmistakably was not aggravated beyond its natural progression by active service. While acknowledging that temporary fluctuations in blood pressure may occur, the examiners explained that medical evidence did not demonstrate permanent worsening attributable to service or a service-connected disability. The examiners further noted that medical literature does not support aggravation of preexisting hypertension due to military service absent evidence of sustained pathological progression.  

The Board finds these opinions persuasive, as they are consistent with the medical evidence of record. While the Veteran is competent to report observable symptoms, the determination of whether hypertension was aggravated beyond its natural progression or is etiologically related to PTSD involves complex medical questions beyond the scope of the Veteran. Jandreau  supra.

Based on the foregoing, the Board concludes that the evidence of record persuasively weighs against a finding that the Veteran's hypertension was caused or aggravated by service-connected PTSD disability. The criteria for service connection are not met, and the appeal is denied.

In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine.  As the evidence persuasively favors one side or the other, the doctrine is not for application.  See Lynch, supra; 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

 

J. Kirby

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T.B.

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.