SLEEP DISTURBANCE

D. MARTZ AMES · 2026 · Case ID: A26026527

MIXED

Summary

The veteran, an Army veteran who served from February 1986 to February 1989, appeals the denial of service connection for insomnia disorder, anxiety disorder, follicular lymphoma, and tension headaches, as well as a hiatal hernia. The Board found that new and relevant evidence was submitted for insomnia, anxiety disorder, and follicular lymphoma, warranting readjudication. Specifically, a September 2024 VA examination diagnosed insomnia and found it related to service-connected tinnitus, a favorable nexus opinion. For anxiety disorder, a September 2024 VA opinion linked it to non-Hodgkin's lymphoma but lacked rationale, and a prior September 2023 opinion also lacked rationale, leading the Board to find these opinions inadequate and remand the claim for a proper opinion. For follicular lymphoma, a May 2024 VA memorandum indicated potential TERA exposure due to the veteran's MOS as a Cavalry Scout, controverting a prior April 2023 opinion that found no presumptive exposures, thus warranting readjudication. The claims for tension headaches and hiatal hernia were remanded because the January 2025 and December 2024 medical opinions, while finding current disabilities, failed to provide separate rationales for both secondary causation and aggravation, which is required for adequacy. The Board found the existing opinions inadequate and remanded these claims for addendum opinions. Service connection for insomnia was granted as secondary to tinnitus.

Rationale

New and relevant evidence submitted (September 2024 VA exam); Veteran diagnosed with insomnia disorder; Examiner found insomnia related to service-connected tinnitus; Examiner deemed competent and credible

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250422-541720

Full Decision Text

Citation Nr: A26026527
Decision Date: 03/24/26 Archive Date: 03/24/26

DOCKET NO. 250422-541720
DATE: March 24, 2026

ORDER

New and relevant evidence having been submitted, readjudication of the Veteran's claim for entitlement to service connection for insomnia disorder is granted.

New and relevant evidence having been submitted, readjudication of the Veteran's claim for entitlement to service connection for an anxiety disorder is granted.

New and relevant evidence having been submitted, readjudication of the Veteran's claim for entitlement to service connection for follicular lymphoma is granted.

Entitlement to service connection for insomnia disorder is granted.

REMANDED

Entitlement to service connection for an anxiety disorder, to include as secondary to service-connected disabilities is remanded.

Entitlement to service connection for tension headaches, to include as secondary to service-connected disabilities is remanded.

Entitlement to service connection for a hiatal hernia, to include as secondary to service-connected disabilities is remanded.

Entitlement to service connection for follicular lymphoma is remanded.

FINDINGS OF FACT

1. New evidence received after the September 2023 rating decision denial is relevant to the issue of entitlement to service connection for insomnia.

2. New evidence received after the September 2023 rating decision denial is relevant to the issue of entitlement to service connection for anxiety disorder.

3. New evidence received after the September 2023 rating decision denial is relevant to the issue of entitlement to service connection for follicular lymphoma.

4. The Veteran's current insomnia is caused or aggravated by his service-connected tinnitus.

CONCLUSIONS OF LAW

1. The criteria for readjudicating the claim for service connection for insomnia have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156.

2. The criteria for readjudicating the claim for service connection for an anxiety disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156.

3. The criteria for readjudicating the claim for service connection for follicular lymphoma have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156.

4. The criteria for service connection for insomnia as secondary to service-connected tinnitus are 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 with the United States Army from February 1986 to February 1989.

The rating decisions on appeal were issued in May 2024, two in December 2024, and January 2025 and each constitute an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. The May 2024 rating decision found that new and relevant evidence had not been submitted to readjudicate the claim for service connection for follicular lymphoma. The December 2024 rating decision found that new and relevant evidence had not been submitted to readjudicate the claims for service connection for anxiety disorder, insomnia, and tension headaches. Another December 2024 rating decision denied service connection for a hiatal hernia. The January 2025 rating decision found that new and relevant evidence had been received to readjudicate the claim for service connection for tension headaches and denied the claim.

In the April 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 agency of original jurisdiction (AOJ) decisions on appeal. 38 C.F.R. § 20.301. Evidence was submitted after the AOJ decisions on appeal and it was not considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. Specific instructions on how to file a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims of entitlement to service connection for an anxiety disorder, tension headaches, a hiatal hernia, and follicular lymphoma, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence in light of the entirety of the record.

New and Relevant Evidence

The VA will readjudicate a claim if new and relevant evidenced is presented or secured. 38 C.F.R. § 3.156 (d). "Relevant evidence" is evidence that tends to prove or disprove a matter in issue. 38 C.F.R. § 3.2501 (a)(1).

This is a lower threshold than the requirement of "new and material evidence" which applied to the legacy appeal system in that "material evidence" had to relate to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156 (a).

1. Whether readjudication of the Veteran's claim for entitlement to service connection for insomnia is warranted based on the submission of new and relevant evidence

In September 2023, the Veteran's claim for service connection for insomnia was denied on the basis that there was no evidence that there was a separate diagnosis of insomnia. In November 2024, the Veteran submitted a supplemental claim to readjudicate service connection for insomnia.

The question in this case is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in September 2023 that tends to prove or disprove one of the elements of service connection.

In September 2024, the Veteran completed a mental disorders examination and was diagnosed with insomnia disorder. The examiner found that the Veteran's insomnia was due to tinnitus. This is new and relevant evidence because it tends to prove the Veteran's claim. New and relevant evidence having been submitted, readjudication of the Veteran's claim for entitlement to service connection for insomnia is warranted.

2. Whether readjudication of the Veteran's claim for entitlement to service connection for an anxiety disorder is warranted based on the submission of new and relevant evidence

In September 2023, the Veteran's claim for service connection for an anxiety disorder was denied on the basis that there was no evidence that the Veteran's anxiety was related to his period of active service. In November 2024, the Veteran submitted a supplemental claim to readjudicate service connection for an anxiety disorder.

At the September 2024 mental disorders examination discussed above, the VA examiner opined that the Veteran's anxiety disorder is due to his non-Hodgkins lymphoma, which is not a service-connected disability. The September 2024 opinion tends to disprove the Veteran's claim and is therefore new and relevant evidence. New and relevant evidence having been submitted, readjudication of the Veteran's claim for entitlement to service connection for an anxiety disorder is warranted.

3. Whether readjudication of the Veteran's claim for entitlement to service connection for follicular lymphoma is warranted based on the submission of new and relevant evidence

In August 2023, the Veteran's claim for service connection for follicular lymphoma was denied on the basis that there was no evidence that the Veteran's follicular lymphoma was related to his period of active service as the Veteran did not participate in a toxic exposure risk activity (TERA) during active service. In May 2024, the Veteran submitted a supplemental claim to readjudicate service connection for follicular lymphoma.

The question in this case is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in August 2023 that tends to prove or disprove one of the elements of service connection.

In May 2024, the VA associated a memorandum with the Veteran's claims file indicating that he participated in
, the Veteran's claim for service connection for follicular lymphoma was denied on the basis that there was no evidence that the Veteran's follicular lymphoma was related to his period of active service as the Veteran did not participate in a toxic exposure risk activity (TERA) during active service. In May 2024, the Veteran submitted a supplemental claim to readjudicate service connection for follicular lymphoma.

In May 2024, the VA associated a memorandum with the Veteran's claims file indicating that he participated in a TERA based on his exposure to vehicle fumes and munitions based on his military occupational specialty of Cavalry Scout. The VA memorandum is new and relevant evidence that the Veteran's follicular lymphoma may be related to his period of active service. New and relevant evidence having been submitted, readjudication of the Veteran's claim for entitlement to service connection for follicular lymphoma is warranted.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

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) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310. Secondary causation exists when, "but for" the service-connected disability, the non-service-connected disability was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain. Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (citations omitted). Secondary aggravation exists when the non-service-connected disability, although not caused by a service-connected disability, would be less severe were it not for a service-connected disability. Id. at 1364. If a disability is service-connected via secondary aggravation, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995).

1. Entitlement to service connection for insomnia disorder, to include as secondary to service-connected tinnitus

The Veteran claims entitlement to service connection for insomnia.

At a September 2024 mental disorders examination, the Veteran was diagnosed with insomnia disorder. The September 2024 examiner noted that the Veteran meets the Diagnostic and Statistical Manual V (DSM-5) criteria for a separate and apart diagnoses of insomnia and anxiety disorder. Accordingly, the Board finds that the Veteran does have a current diagnosis of insomnia.

Further, following an in-person examination and review of the Veteran's medical history, the September 2024 examiner determined that the Veteran's current insomnia was related to his service-connected tinnitus. The Board finds that the September 2024 examiner is competent and credible. The September 2024 examiner's opinion is highly probative evidence in favor of the Veteran's claim for service connection.

Based on the most persuasive evidence of record, the Board finds that entitlement to service connection for insomnia disorder on a secondary causation basis, is warranted.

REASONS FOR REMAND

1. Entitlement to service connection for anxiety disorder, to include as secondary to service-connected tinnitus

The Veteran claims entitlement to service connection for anxiety disorder. In his August 2024 claim, he stated that it was due to his service-connected tinnitus. He also stated that it was due to an event or injury in service but did not provide further detail. In a June 2024 rating decision, the AOJ granted service connection for tinnitus, and therefore the Veteran's tinnitus was service-connected during the development of this claim.

A
the most persuasive evidence of record, the Board finds that entitlement to service connection for insomnia disorder on a secondary causation basis, is warranted.

REASONS FOR REMAND

1. Entitlement to service connection for anxiety disorder, to include as secondary to service-connected tinnitus

A September 2024 mental disorders examination noted that the Veteran has a diagnosis of anxiety disorder. At issue in the Veteran's claim is whether his current anxiety disorder was incurred during or caused by his period of active service, or whether it was caused or aggravated by his service-connected disabilities.

The September 2024 mental disorder examiner noted that the Veteran's anxiety disorder is related to his non-hodgkin's lymphoma diagnosis but provides no rationale for the conclusion. A September 2023 mental disorders examination noted that the "Veteran has medical conditions, specifically a blood cancer, that is the proximate cause of his current symptoms of anxiety" but does not provide a rationale for the conclusion. The Board finds that the September 2024 and September 2023 examiner conclusions are inadequate for purposes of determining service connection. Medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient rationale. Jones v. Shinseki, 23, Vet. App. 382, 389-90 (2010); 38 C.F.R. § 3.10. A medical opinion without rationale is not probative. Miller v. West, 11 Vet. App. 345 (1998). Once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

The record does not contain an adequate medical opinion regarding the etiology of the Veteran's anxiety disorder. Failure to obtain an adequate medical opinion regarding the etiology of the Veteran's anxiety disorder is a pre-decisional failure of the duty to assist. The Board finds that an adequate medical opinion is necessary to comprehensively evaluate the Veteran's claim for service connection.

2. Entitlement to service connection for tension headaches, to include as secondary to service-connected tinnitus

3. Entitlement to service connection for hiatal hernia, to include as secondary to service-connected benign neoplasm of the kidney

The Veteran claims entitlement to service connection for tension headaches and hiatal hernia. In his August 2024 claim, the Veteran asserted that his headaches are due to his tinnitus. In his October 2024 claim, the Veteran asserted that his hiatal hernia was due to treatment for his service-connected benign neoplasm of the kidney at a VA medical facility in Loma Linda in September 2020. He stated that the tumor was so large that it pulled through his abdomen, resulting in a hernia.

In a June 2024 rating decision, the AOJ granted service connection for tinnitus, and therefore the Veteran's tinnitus was service-connected during the development of his claim for service connection for tension headaches. In a February 2024 rating decision, the AOJ granted service connection for the Veteran's benign neoplasm of the kidney, and therefore his benign neoplasm of the kidney was service-connected during the development of his claim for service connection for a hiatal hernia.

The January 2025 and December 2024 rating decisions on appeal each note a favorable finding that the Veteran has a current disability. Medical opinions regarding the etiology of the Veteran's claimed disabilities were obtained in January 2025 and December 2024. Each of the medical opinions addressed whether the Veteran's claimed disabilities were caused by his service-connected disabilities. However, each of the medical opinions fails to address if the Veteran's claimed disabilities were aggravated by his service-connected disabilities.

The record does not contain adequate medical opinions regarding the etiology of the Veteran's tension headaches and hiatal hernia. To be adequate, a VA opinion must provide separate rationales for both secondary causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018).

Failure to obtain medical opinions regarding the etiology of the Veteran's tension headaches and hiatal hernia is a pre-decisional failure of the duty to assist. The Board finds that addendum medical opinions are necessary to comprehensively evaluate the Veteran's claims for service connection.

4. Ent
each of the medical opinions fails to address if the Veteran's claimed disabilities were aggravated by his service-connected disabilities.

4. Entitlement to service connection for follicular lymphoma

The Veteran claims entitlement to service connection for follicular lymphoma. Specifically, the Veteran contends that his claimed follicular lymphoma was caused by his TERA during his period of active service.

An April 2023 medical opinion concluded that the Veteran's follicular lymphoma was less likely than not caused by his period of active service because there was "no presumptive exposures during service, no Persian Gulf Service, and no actionable non-deployment related exposures during service." However, A May 2024 VA memorandum established a non-deployment related TERA due to the Veteran's military occupational specialty as a Cavalry Scout. Accordingly, the Board finds that the April 2023 medical opinion is inadequate as it is controverted by the evidence of record.

Failure to obtain an adequate medical opinion regarding the etiology of the Veteran's claimed follicular lymphoma a is a pre-decisional failure of the duty to assist. The Board finds that an adequate medical opinion is necessary to comprehensively evaluate the Veteran's claim for service connection.

The matters are REMANDED for the following action:

1. Provide the Veteran's claims file to a clinician to discuss his diagnosed anxiety disorder. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the clinician.

The clinician must provide an opinion as to:

a. Whether the Veteran's anxiety disorder began during active service, or is related to an incident of service.

b. Whether the Veteran's anxiety disorder is due to his service-connected tinnitus.

c. Whether the Veteran's anxiety disorder is aggravated by his service-connected tinnitus.

The clinician must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such conclusion.

2. Provide the Veteran's claims file to a clinician to discuss his tension headaches. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the clinician.

The clinician must provide an opinion as to:

a. Whether the Veteran's tension headaches are aggravated by his service-connected tinnitus.

3. Provide the Veteran's claims file to a VA clinician qualified to discuss his hiatal hernia. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the clinician.

The clinician must provide an opinion as to:

a. Whether the Veteran's hiatal hernia is aggravated by his service-connected benign neoplasm of the kidney.

4. Review all evidence in the Veteran's claims file to determine if a probative medical opinion regarding the Veteran's follicular lymphoma has been obtained. If so, adjudicate the Veteran's claim for service connection with all the evidence of record. If not, provide the Veteran's claims file to a VA clinician qualified to discuss his follicular lymphoma. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner.

The examiner must provide an opinion as to:

a. Does the Veteran have a current diagnosis of follicular lymphoma?

b. If so, is the Veteran's follicular lymphoma due to his in-service TERA?

The examiner must provide all findings,
file to determine if a probative medical opinion regarding the Veteran's follicular lymphoma has been obtained. If so, adjudicate the Veteran's claim for service connection with all the evidence of record. If not, provide the Veteran's claims file to a VA clinician qualified to discuss his follicular lymphoma. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner.

The examiner must provide an opinion as to:

a. Does the Veteran have a current diagnosis of follicular lymphoma?

b. If so, is the Veteran's follicular lymphoma due to his in-service TERA?

The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion.

D. Martz Ames

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Riordan, 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.

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