SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, a Veteran who served from October 1999 to September 2003, including service in Qatar during Operation Enduring Freedom, appeals the denial of service connection for obstructive sleep apnea (OSA). The Veteran claimed OSA was due to Persian Gulf environmental hazards and also asserted it was secondary to his service-connected left knee disability, which he believed led to obesity. He submitted lay statements from himself and his wife describing symptoms like snoring and daytime fatigue, and a private medical opinion from Dr. Brodner, who opined OSA was present in service and diagnosed it as a chronic disease. The Board found Dr. Brodner's opinion to have reduced probative weight, citing its reliance on lay evidence and generalizations, and its failure to address the lack of in-service symptom reporting or the Veteran's denial of sleep issues on his enlistment examination. Conversely, the Board found the VA examiners' opinions from March 2021, April 2021, and September 2024 to be most probative. These examiners noted the absence of in-service OSA documentation, the Veteran's denial of sleep issues on his enlistment and separation physicals, and the 13-year gap between service and diagnosis. They concluded it was less likely than not that OSA was related to service or aggravated by his left knee disability, citing the lack of continuity of care and the primary role of obesity and other factors in OSA development. The Board also rejected the claim for presumptive service connection for OSA as a medically unexplained chronic multi-symptom illness (MUCMI) because OSA has a known etiology. Service connection for OSA was denied.

Rationale

Conflicting medical opinions regarding OSA etiology.; Board found VA examiners' opinions more probative than private opinion.; Lack of in-service documentation of OSA symptoms.; Significant delay between service and diagnosis.; OSA has a known etiology, precluding presumptive service connection as MUCMI.

Full Decision Text

Citation Nr: A26022920
Decision Date: 03/13/26	Archive Date: 03/13/26

DOCKET NO. 251126-610967
DATE: March 13, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea (OSA), to include as due to exposure to environmental hazards in the Persian Gulf and as secondary to service-connected left knee degenerative arthritis with residual posterior cruciate ligament tear (left knee disability), is denied.

FINDING OF FACT

The Veteran's OSA did not originate in service, within a year of service, and is not otherwise etiologically related to his active service or to his service-connected left knee disability.

CONCLUSION OF LAW

The criteria for service connection for OSA have not been met.  38 U.S.C. §§ 1110, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from October 1999 to September 2003.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2025 rating decision adjudicated under the Appeals Modernization Act (AMA) by a Department of Veterans Affairs (VA) Regional Office (RO).  The Veteran was notified of the January 2025 rating decision in a February 2025 letter.  See February 2025 Notification Letter (e.g., VA Form 20-8993, VA Form 21-0290, PCGL).

Within the framework of the AMA, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) and elected Direct Review by a Veterans Law Judge in November 2025.  See November 2025 VA Form 10182 Notice of Disagreement.  The Board notes that under the direct review option, no additional evidence received after the appealed rating decision is to be considered; rather, review is limited to the evidence on record at the time of that decision.  38 C.F.R. §§ 19.2(d), 20.301.

Lastly, the Board notes that additional evidence, to include updated VA treatment records, was added to the claims file during a period of time when new evidence was not allowed.  Therefore, the Board may not consider this evidence.  38 C.F.R. §§ 3.2500, 20.302(a).  However, the Veteran may file a Supplemental Claim and submit or identify this evidence.  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.  38 C.F.R. § 3.2501.  Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303.  Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); 38 C.F.R. § 3.303.

Entitlement to service connection for OSA, to include as due to exposure to environmental hazards in the Persian Gulf and as secondary to service-connected left knee disability, is denied.

The Veteran states that his diagnosed OSA symptoms, to include loud snoring, extreme fatigue, stopping breathing during sleep, sleep disturbances, and heart palpitations, manifested while he was serving on active duty and reported that he has continued to experience such symptoms since service.  In this regard, he stated that his diagnosed OSA may have been caused by exposure to environmental hazards in the Persian Gulf.  He further explained that he snored so loudly that airmen serving alongside him in Qatar joked that his snoring would wake up the whole tent.  He also stated that daytime fatigue symptoms caused him to doze off while he was on duty and noted that another airman had to drive out to his duty station to check on him on two occasions during his deployment.  See November 2016 VA Form 21-526EZ, Fully Developed Claim (Compensation); February 2018 NOD; April 2019 Medical Treatment Record - Non-Government Facility; November 2019 VA Form 20-0996 Request for Higher-Level Review.

Alternatively, the Veteran asserted that service
 by exposure to environmental hazards in the Persian Gulf.  He further explained that he snored so loudly that airmen serving alongside him in Qatar joked that his snoring would wake up the whole tent.  He also stated that daytime fatigue symptoms caused him to doze off while he was on duty and noted that another airman had to drive out to his duty station to check on him on two occasions during his deployment.  See November 2016 VA Form 21-526EZ, Fully Developed Claim (Compensation); February 2018 NOD; April 2019 Medical Treatment Record - Non-Government Facility; November 2019 VA Form 20-0996 Request for Higher-Level Review.

Alternatively, the Veteran asserted that service connection for OSA may be warranted on a presumptive basis pursuant to 38 U.S.C. § 1117.  In this regard, he stated that sleep apnea was defined by a cluster of signs and symptoms, such as respiratory and sleep disturbance, and as such, that it satisfied the requirements for a medically unexplained chronic multi-symptom illness (MUCMI) under 38 C.F.R. § 3.317.  See February 2021 VA Form 20-0996 Request for Higher-Level Review.

In addition, the Veteran stated that his diagnosed OSA may have been caused or aggravated by his service-connected left knee disability.  Specifically, he noted that he weighed 180 lbs. prior to his left knee injury in November 2002 and explained that functional limitations and pain caused by his left knee disability led him to steadily gain weight.  In this regard, the Veteran stated that his obesity progressed along with the pain and functional limitations imposed by his service-connected left knee disability, and as such, argued that his OSA was caused or aggravated by his service-connected OSA with obesity as an intermediate step.  See February 2021 VA Form 20-0996 Request for Higher-Level Review; September 2021 VA Form 10182 Notice of Disagreement.

In support of his claim, the Veteran submitted a statement from his wife dated in March 2019.  The Veteran's wife indicated that she had been married to the Veteran since July 1999 and stated that she first noticed his sleeping issues, to include excessive loud snoring, apneic episodes, and daytime fatigue, while the Veteran was stationed at Vandenberg Air Force Base in or around Spring 2002.  She also indicated that the Veteran began having additional symptoms, to include heart palpitations, in 2003 and reported that he continued to experience progressively worsening symptoms until he was diagnosed with OSA in 2016.  See April 2019 Medical Treatment Record - Non-Government Facility.  

A March 2024 toxic exposure risk activity memorandum confirms that the Veteran served in Qatar from October 2001 to November 2001, and as such, he satisfies the criteria for presumptive toxic exposure under 38 U.S.C. § 1119 and for designation as a "Persian Gulf Veteran" pursuant to 38 U.S.C. § 1117.  See March 2024 Other. 

A review of the service treatment records (STRs) shows an August 1999 enlistment report of medical examination, which notes the Veteran's mouth, throat, lungs, chest, and neurologic system to be normal, and the Veteran denied frequent trouble sleeping and palpitations or pounding heart on the corresponding report of medical history.  A November 2001 post-deployment health assessment shows that the Veteran was deployed to Qatar in support of Operation Enduring Freedom.  During the assessment, the Veteran reported that his general health was excellent and stated that he did not have any unresolved medical or dental problems that developed during the deployment.  Following the assessment, the examiner found that the Veteran did not require a referral for fatigue, malaise, multi-symptom complaints, or for any other problems.

In April 2003, the Veteran sought emergency medical treatment for an irregular heartbeat and palpitations.  In this regard, he explained that he had felt his heart skip individual beats in the past but reported that his current symptoms included lots of skipped heartbeats and weakness.  He also indicated that he played basketball two to three times per week, to include earlier that night, and the examiner stated that the Veteran had not had enough fluids.  The examiner diagnosed acute palpitations - premature ventricular contractions related to low magnesium, and indicated that his symptoms resolved after he was given magnesium and potassium.  The Veteran attended a follow-up appointment related to his heart spasms and palpitations one day later.  The assessment included subjective heart palpitations, and the examiner advised reassurance with observation.  Thereafter, an August 2003 separation physical and report of medical assessment shows that the Veteran's overall health had remained the same since he last underwent a medical assessment
 symptoms included lots of skipped heartbeats and weakness.  He also indicated that he played basketball two to three times per week, to include earlier that night, and the examiner stated that the Veteran had not had enough fluids.  The examiner diagnosed acute palpitations - premature ventricular contractions related to low magnesium, and indicated that his symptoms resolved after he was given magnesium and potassium.  The Veteran attended a follow-up appointment related to his heart spasms and palpitations one day later.  The assessment included subjective heart palpitations, and the examiner advised reassurance with observation.  Thereafter, an August 2003 separation physical and report of medical assessment shows that the Veteran's overall health had remained the same since he last underwent a medical assessment/physical examination.  Notably, he did not report any findings or symptoms related to OSA at that time.  See February 2004 STR - Medical; April 2004 STR - Medical - Photocopy.

A review of the post-service medical records shows that the Veteran underwent a VA general medical examination in May 2004.  During the examination, the Veteran denied night sweats, malaise, and palpitations.  See May 2004 VA examination.  Significantly, he did not report any findings or symptoms related to OSA at that time.

In June 2016, the Veteran requested a referral for a sleep study and indicated that he had been snoring a lot and waking up in the middle of the night to catch his breath.  Thereafter, a September 2016 evaluation and management note shows that the Veteran endorsed daytime fatigue, irritability, heavy snoring, and waking up feeling as though he was choking.  He subsequently underwent an unattended three channel home based sleep study and was diagnosed with severe OSA and significant oxyhemoglobin desaturations in September 2016.  See April 2023 CAPRI.

In support of his claim, the Veteran submitted a private medical opinion from Dr. D. C. Brodner dated in March 2019.  After interviewing the Veteran and reviewing the evidence of record, to include the March 2019 lay statement from the Veteran's wife, Dr. Brodner opined that it was more likely than not that the Veteran's OSA was present during service.  In support of his opinion, Dr. Brodner explained that OSA was conceptualized as a chronic disease requiring years to develop across a continuum, the beginning of which was typically signaled by snoring.  In this regard, he found that the presence of snoring indicated the existence of OSA, even in its earliest form.  

Dr. Brodner further stated that snoring marked the beginning in the natural course of OSA but explained that years generally passed before an individual sought treatment or received a diagnosis because the snoring was ignored as an annoying social problem until it gradually worsened over time.  In this regard, he explained that an event, such as the development of a severe medical issue, witnessed choking or gasping, or notice by a physician, was generally needed to trigger evaluation and diagnosis.  Thus, Dr. Brodner stated that snoring and other OSA symptoms, to include daytime sleepiness, are often unreported and misinterpreted as common and normal, and as such found that the fact that the Veteran's OSA diagnosis was postponed until years after he was discharged from active duty, despite being witnessed by fellow airmen and his wife, was consistent with the progression of OSA.  

In addition, Dr. Brodner referenced a study, which found that the average time that elapsed between when an individual first recognized a major feature of OSA and when they were referred for testing was 87.5 months, or more than seven years.  In this regard, he stated that such data suggested that both a lack of reporting of symptoms by OSA patients and the failure of health care providers to obtain an appropriate sleep history contributed to a significant delay in OSA diagnoses.  In this regard, he stated that a missed opportunity to recognize the Veteran's OSA was demonstrated in the August 1999 enlistment report of medical examination, which failed to show that the examiner inquired about snoring or sleep issues.  

He further stated that the Veteran's STRs may be silent for documentation of OSA despite multiple interactions with medical personnel because his in-service health care providers were not inquiring about, or testing for, OSA signs or symptoms.  Thus, Dr. Brouder concluded that the lay evidence of record clearly showed that the Veteran exhibited the cardinal signs and symptoms of OSA during service, and as explained by the conceptualization of OSA as a disorder progressing along a continuum from simple snoring to systemic disease, that it was incontrovertible that the Veteran's OSA existed in its nascent form during service despite the absence of a formal diagnosis.  See
 which failed to show that the examiner inquired about snoring or sleep issues.  

He further stated that the Veteran's STRs may be silent for documentation of OSA despite multiple interactions with medical personnel because his in-service health care providers were not inquiring about, or testing for, OSA signs or symptoms.  Thus, Dr. Brouder concluded that the lay evidence of record clearly showed that the Veteran exhibited the cardinal signs and symptoms of OSA during service, and as explained by the conceptualization of OSA as a disorder progressing along a continuum from simple snoring to systemic disease, that it was incontrovertible that the Veteran's OSA existed in its nascent form during service despite the absence of a formal diagnosis.  See April 2019 Medical Treatment Record - Non-Government Facility. 

The Veteran underwent a VA examination for sleep apnea in December 2019.  The examiner noted that the Veteran had been diagnosed with OSA.  During the examination, the Veteran reported that his OSA manifested in the mid-2000s and explained that he began to develop sleep issues after he was exposed to environmental hazards in the Persian Gulf.  In this regard, he noted that his symptoms progressed over time with continued snoring and daytime somnolence.  

After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed OSA was incurred in or caused by the claimed in-service injury, event, or illness.  In support of his opinion, the examiner stated that there was no documentation to show that the Veteran's OSA manifested in service.  He further stated that heart palpitations did not lead to OSA and that he could not link the two with a more than 50 percent certainty.  See January 2020 C&P examination.

The Veteran submitted an addendum medical opinion from Dr. Brodner dated in February 2020.  Dr. Brodner stated that his March 2019 medical opinion was based on an analysis of the entirety of the Veteran's STRs, including his claims file, evidence provided by the Veteran's own history and lay statements, peer-reviewed medical literature, his first-hand clinical experience, and the generally-recognized nature of OSA as a chronic disease that slowly progressed along a continuum from snoring to the development of potentially fatal medical co-morbidities.  See February 2020 Medical Treatment Record - Non-Government Facility.  

In June 2020, VA obtained an addendum medical opinion from the examiner who performed the December 2019 VA examination for sleep conditions.  The examiner indicated that he reviewed the March 2019 private medical opinion from Dr. Brodner in connection with his opinion.  In this regard, he acknowledged Dr. Brodner's reports that he reviewed the Veteran's medical records in connection with his opinion but emphasized that he did not report finding any reference to OSA, or any sleep apnea related symptoms, to include snoring, daytime somnolence, etc., therein.  Rather, the examiner stated that the private physician appeared to base his entire opinion the lay evidence of record, to include statements from the Veteran and his wife, which indicated that he had been snoring and experiencing other sleep issues since 2002.  In contrast, the VA examiner stated that he based his December 2019 medical opinion on the fact that the STRs did not show that the Veteran experienced any OSA precursor symptoms in service.  See June 2020 C&P examination.  

In February 2021, the Veteran's attorney argued that the December 2019 and June 2020 VA examiner's opinions should be considered inadequate because the examiner did not provide any clinical data to support his stated opinions.  In this regard, the attorney stated that the examiner essentially resorted to mere speculation as the medical opinions completely lacked a reasoned medical explanation.  The attorney further argued that the December 2019 and June 2020 VA medical opinions were based entirely on the lack of STRs documenting OSA and emphasized that the examiner did not consider whether the Veteran's lay statement presented sufficient evidence of the etiology of his disability such that his claim of service connection could be proven.  

In contrast, the Veteran's attorney argued that the March 2019 private medical opinion from Dr. Brodner, a double Board-certified physician in Otolaryngology and sleep medicine with expertise in the evaluation and management of OSA, should be considered the most probative evidence of record.  In this regard, he stated that Dr. Brodner's opinion was founded on a complete review of the claims file and an interview with the Veteran and was supported by the particular facts of his medical history.  See February 2021 VA Form 20-0996 Request for Higher-Level Review.

The Veteran next underwent a VA examination for OSA in March
 of his disability such that his claim of service connection could be proven.  

In contrast, the Veteran's attorney argued that the March 2019 private medical opinion from Dr. Brodner, a double Board-certified physician in Otolaryngology and sleep medicine with expertise in the evaluation and management of OSA, should be considered the most probative evidence of record.  In this regard, he stated that Dr. Brodner's opinion was founded on a complete review of the claims file and an interview with the Veteran and was supported by the particular facts of his medical history.  See February 2021 VA Form 20-0996 Request for Higher-Level Review.

The Veteran next underwent a VA examination for OSA in March 2021.  The examiner noted that the Veteran had been diagnosed with OSA.  During the examination, the Veteran reported that his OSA symptoms, to include daytime somnolence and nighttime choking and snoring, manifested while he was serving on active duty in or around 2002.  He further explained that he did not seek treatment for his symptoms until 2016, when he underwent a sleep study and was initially diagnosed with OSA.  

After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's OSA was incurred in or caused by his claimed in-service injury, event, or illness.  In support of her opinion, the examiner explained that there was no objective medical evidence to show that the Veteran experienced any signs or symptoms of OSA during service or shortly after he was discharged from active duty.  Rather, the examiner stated that the first evidence showing that the Veteran experienced signs or symptoms of OSA was documented when he was worked up for, and diagnosed with, OSA in 2016, approximately 13 years after he was discharged from active duty.  Thus, the examiner emphasized that the objective evidence of record did not show any continuity of care for 13 years after the Veteran was discharged from active duty, and as such, found that a nexus could not be established between the Veteran's diagnosed OSA and his active service.

In addition, the examiner opined that it was less likely than not that the heart palpitations the Veteran reported in service were caused by his diagnosed OSA.  In support of her opinion, the examiner acknowledged that the Veteran's STRs showed that he sought emergency medical treatment for episodic heart palpitations in 2003 but emphasized that he was diagnosed with premature ventricular contractions related to low magnesium, which resolved after he received magnesium and potassium, at that time.  She further noted that a subsequent April 2003 STR showed that the Veteran was diagnosed with subjective palpitations and advised reassurance with observation.  The examiner further noted that the Veteran did well until he was diagnosed with an atrial septal defect in 2012 and emphasized his reports that he was told that his cardiac condition was congenital.  See March 2021 C&P examination; see also April 2023 C&P examination.

The Veteran also underwent a VA Gulf War general medical examination in March 2021.  On examination, the examiner found that the Veteran did not have any diagnosed illness for which no etiology had been established and indicated that he did not report any additional signs and/or symptoms that may represent an undiagnosed illness or a diagnosed MUCMI.  See March 2021 C&P examination.  

The Veteran was next afforded a VA examination for sleep apnea in April 2021.  The examiner diagnosed OSA.  During the examination, the Veteran reported that his OSA symptoms, to include daytime somnolence, nighttime choking, and snoring, manifested while he was serving on active duty in 2002, though he also acknowledged that he did not seek medical attention for his symptoms until 2016.  He further stated that he experienced heart palpitations, which he believed to be related to his OSA because they occurred when he did not have a good sleep.  

However, after performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's OSA was incurred in or caused by the claimed in-service injury, event, or illness.  In support of her opinion, the examiner stated that the Veteran's heart palpitations could not be directly linked to his OSA.  Rather, she emphasized that the Veteran had a significant cardiac history.  

In this regard, she noted that the heart palpitations reported by the Veteran were found to be related to his low magnesium level and resolved after he was given magnesium and potassium.  The examiner further emphasized that the Veteran was diagnosed with congenital atrial septal defect in 2012 and underwent an atrial septal defect repair.  In this regard, the examiner found that there was no credible medical research establishing a caus
 that the Veteran's OSA was incurred in or caused by the claimed in-service injury, event, or illness.  In support of her opinion, the examiner stated that the Veteran's heart palpitations could not be directly linked to his OSA.  Rather, she emphasized that the Veteran had a significant cardiac history.  

In this regard, she noted that the heart palpitations reported by the Veteran were found to be related to his low magnesium level and resolved after he was given magnesium and potassium.  The examiner further emphasized that the Veteran was diagnosed with congenital atrial septal defect in 2012 and underwent an atrial septal defect repair.  In this regard, the examiner found that there was no credible medical research establishing a causative relationship between atrial septal defects and OSA.  As such, the examiner found that it was less likely than not that the Veteran's heart palpitations were directly related to his OSA.  See April 2021 C&P examination.  

The examiner further found the Veteran's diagnosed OSA was a disease with a specific etiology and diagnosis and opined that it was less likely than not that such was incurred in or caused by his exposures to environmental hazards while he was serving in Southwest Asia.  In support of her opinion, the examiner explained that OSA is an anatomical condition in which the structures of the upper airway relaxed and prolapsed during sleep, resulting in the temporary occlusion of the airway.  As such, the examiner found that it was less likely than not that the Veteran's disability pattern or diagnosed disease was related to a specific exposure event experienced by the Veteran during service in Southwest Asia.  See April 2021 Medical Opinion.

The Veteran last underwent a VA examination for sleep apnea in September 2024.  The examiner diagnosed OSA.  During the examination, the Veteran reported that his OSA symptoms manifested in 2002, when his wife told him that he was snoring and experiencing apneic episodes.  He further stated that he sought medical care for his symptoms in or around 2016 and was subsequently diagnosed with OSA.  See September 2024 C&P examination.

After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed OSA was proximately due to, the result of, or aggravated beyond its natural progression by his service-connected left knee disability.  In support of her opinion, the examiner detailed the Veteran's relevant medical history and noted that he underwent a sleep study and was diagnosed with OSA in September 2016.  

The examiner further stated that clinical risk factors for OSA included advancing age, male gender, obesity, and craniofacial morphology or upper airway soft tissue abnormalities.  In this regard, she explained that obesity resulted from a combination of causes and contributing factors, including individual factors such as behavior and genetics, behaviors including dietary patterns, physical activity, inactivity, medication use, and other exposures.  The examiner further noted that weight gain was a result of imbalance of calories consumed with calories expended.

In addition, the examiner acknowledged that the Veteran's left knee disability caused some physical limitations but emphasized that the objective evidence of record did not show that such limitations would preclude him from all forms of exercising or from eating a well-balanced caloric meal.  In this regard, she noted that medical guidelines for treating orthopedic disabilities included exercise as one of the prescribed treatments to prevent increased joint pain and stiffness and to avoid limitations in range of motions.  She further emphasized that the Veteran was repeatedly referred to physical therapy to treat his service-connected left knee disability and his other nonservice-connected orthopedic disabilities.  

She also indicated that the medical evidence of record showed that the Veteran continued to play basketball before and after he was diagnosed with OSA and that he reported that he walked around his community every other day for 30 to 40 minutes and coached flag football two times per week for exercise, which further showed that his left knee disability did not limit him from being active or exercising.  The examiner also stated that the Veteran was employed and worked full time as a media producer with no physical restrictions and noted that he had to travel frequently for his occupation, which further indicated that he was not limited by his left knee disability.

Thus, the examiner reiterated that caloric balance was the primary driver of weight gain and weight loss such that a caloric surplus resulted in weight gain and a sufficient caloric deficit resulted in weight loss and emphasized that such was true regardless of the level of exercise an individual may or may engage in.  As such, while the examiner acknowledged that obesity was one risk factor in causing the Veteran's obesity, she found that his obesity was not due to his service-connected left knee disability.  Therefore, the examiner opined it was less likely than not that the Veteran's OSA was proximately due to
 with no physical restrictions and noted that he had to travel frequently for his occupation, which further indicated that he was not limited by his left knee disability.

Thus, the examiner reiterated that caloric balance was the primary driver of weight gain and weight loss such that a caloric surplus resulted in weight gain and a sufficient caloric deficit resulted in weight loss and emphasized that such was true regardless of the level of exercise an individual may or may engage in.  As such, while the examiner acknowledged that obesity was one risk factor in causing the Veteran's obesity, she found that his obesity was not due to his service-connected left knee disability.  Therefore, the examiner opined it was less likely than not that the Veteran's OSA was proximately due to, the result of, or aggravated beyond its natural progression by his service-connected left knee disability, to include as due to obesity as an intermediate step between his service-connected left knee disability and his diagnosed OSA.  See September 2024 C&P examination.  

Lastly, in November 2025, the Veteran's attorney argued that the December 2019 and June 2020 VA medical opinions were inadequate because the examiners did not discuss the lay evidence of record or consider whether the Veteran's lay statements presented sufficient evidence of the etiology of his disability such that his service connection claim could be proven.  In contrast, the Veteran's attorney argued that the March 2019 private medical opinion from Dr. Brodner should be considered the most probative evidence of record because the private physician's opinion was founded on a complete review of the claims file and on an interview with the Veteran, and was supported by the particular facts of his medical history.  See November 2025 VA Form 10182 Notice of Disagreement.

Following a review of the evidence of record, the Board finds that service connection for OSA is not warranted.  

The Board recognizes that there is conflicting medical evidence of record regarding the etiology of the Veteran's diagnosed OSA.  In this regard, the Board finds the March 2021, April 2021,  and September 2024 VA examiners' findings to be the most probative evidence of record.

In this regard, the Board acknowledges and has considered the Veteran's attorney's arguments that the March 2019 private medical opinion from Dr. Brodner should be considered the most probative evidence of record.  However, after a thorough review of the evidence, the Board affords the March 2019 and February 2020 private medical opinions from Dr. Brodner reduced probative weight.  In this regard, although he indicated that he reviewed the claims file in connection with his opinion, the Board finds that Dr. Brodner based his opinion in large part on the lay evidence of record and relied on generalizations about the progression of OSA, to include his finding that snoring, in and of itself, indicated the presence of OSA, to support his opinion.  The Board further emphasizes that the private physician did not discuss the significance, if any, of evidence showing that the Veteran did not report that his symptoms began in service when he initially sought treatment for OSA symptoms in 2016.  

Moreover, the Board finds that Dr. Brodner based his opinion, at least in part, on his finding that the examiner who performed the Veteran's August 1999 enlistment report of medical examination failed to inquire about sleep or snoring issues.  In this regard, he hypothesized that the Veteran's STRs may be silent for documentation of OSA despite multiple interactions with medical personnel because his in-service health care providers were not inquiring about, or testing for, OSA signs or symptoms.  However, the private physician failed to address evidence showing that the Veteran explicitly denied frequent trouble sleeping on his August 1999 enlistment report of medical history.  

Moreover, the Board notes that the Veteran reported that his general health was excellent and stated that he did not have any unresolved medical or dental problems that developed while he was deployed to Qatar during his November 2001 post-deployment health assessment, and the examiner found that he did not require a referral for fatigue, malaise, multi-symptom complaints, or for any other problems at that time.  The Board further emphasizes that Dr. Brodner did not reference any other specific medical records, other than the Veteran's September 2016 home based sleep study, to support his opinion.  Thus, for the reasons stated above, the Board affords the March 2019 and February 2020 private medical opinions from Dr. Brodner reduced probative weight.

In contrast, the Board finds the March 2021, April 2021, and September 2024 VA examiners' opinions to be the most probative evidence of record.  In this regard, the Board finds that the examiners considered all pertinent evidence of record, to
aise, multi-symptom complaints, or for any other problems at that time.  The Board further emphasizes that Dr. Brodner did not reference any other specific medical records, other than the Veteran's September 2016 home based sleep study, to support his opinion.  Thus, for the reasons stated above, the Board affords the March 2019 and February 2020 private medical opinions from Dr. Brodner reduced probative weight.

In contrast, the Board finds the March 2021, April 2021, and September 2024 VA examiners' opinions to be the most probative evidence of record.  In this regard, the Board finds that the examiners considered all pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided complete rationales, relying on and citing to the records reviewed.  Moreover, the opinions include clear conclusions with supporting data, as well as reasoned medical explanations connecting the two.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions").  

Moreover, in determining whether the Veteran's OSA qualifies as a MUCMI attributable to Gulf War service, the Board finds the April 2021 VA examiner's opinion to be the most probative evidence of record.  Specifically, the examiner explained OSA is an anatomical condition in which the structures of the upper airway relax and prolapse during sleep, resulting in the temporary occlusion of the airway.  Thus, the pathophysiology and etiology of the Veteran's OSA are at least partially understood.  See Stewart v. Wilkie, 30 Vet. App. 383 (2018).  Accordingly, service connection on a presumptive basis as due to a MUCMI attributable to Gulf War service is not warranted.  

In reaching the above conclusions, the Board has considered the reports from the Veteran and his wife indicating that his OSA symptoms, to include excessive loud snoring, witnessed apneic episodes, and daytime sleepiness, manifested while he was serving on active duty in or around 2002 and continued thereafter.  However, the Board finds that the above lay assertions are not supported by the more probative evidence of record.  In this regard, the Board emphasizes that the Veteran did not report any findings or symptoms related to OSA, and in fact denied night sweats, malaise, and palpitations, when he originally underwent a VA general medical examination in May 2004.  

In addition, although the Veteran reported that he did not seek treatment for his symptoms during or after service, there is no indication that he reported that his OSA manifested during or immediately after service when he initially sought treatment for daytime fatigue, heavy snoring, and waking up feeling as though he was choking in 2016.  The Board finds it logical to assume that had the Veteran been experiencing OSA symptoms since service as reported, such would have been indicated in the medical records leading up to his OSA diagnosis.  Thus, the Board does not find lay reports indicating that the Veteran's OSA symptoms manifested in service and continued thereafter to be persuasive.  The Board is unable to credit the Veteran and his wife's lay reports first made decades after his military service, and instead finds more persuasive the contemporaneous medical records which do not reflect sleep related complaints.  

In addition, the Board recognizes the Veteran's reports that his diagnosed OSA may have been caused by exposure to environmental hazards in the Persian Gulf and/or that it may have been caused or aggravated by weight gain and obesity related to his service-connected left knee disability.  The Board further recognizes the Veteran's reports that the heart palpitations he experienced in service were related to his diagnosed OSA.  However, the question of whether such a relationship exists is a complex medical issue that is far beyond the purview of a lay person.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (providing that the question of whether lay evidence is competent and sufficient is an issue of fact that is to be addressed by the Board).

Thus, the Board finds that any lay assertions by the Veteran and his wife in the present case are outweighed by the medical evidence of record, to include the March 2021, April 2021, and September 2024 VA medical opinions.  As stated above, the VA examiners have the training, knowledge, and expertise on which they relied to form their opinions and provided
 is a complex medical issue that is far beyond the purview of a lay person.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (providing that the question of whether lay evidence is competent and sufficient is an issue of fact that is to be addressed by the Board).

Thus, the Board finds that any lay assertions by the Veteran and his wife in the present case are outweighed by the medical evidence of record, to include the March 2021, April 2021, and September 2024 VA medical opinions.  As stated above, the VA examiners have the training, knowledge, and expertise on which they relied to form their opinions and provided persuasive rationales.  

Based on the foregoing, the Board finds that the third Shedden requirement has not been met.  Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the evidence is persuasively against the claim for service connection for OSA.  The claim is denied.  See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391, 1394 (Fed. Cir. 2021).

 

 

S. HENEKS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	K. Justis, 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.