SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

COLLEEN M. GLASER-ALLEN · 2026 · Case ID: A26036777

GRANTED

Summary

The Veteran, an Army veteran who served from September 1989 to October 1992, including service in Southwest Asia, appeals the denial of service connection for obstructive sleep apnea (OSA). The Veteran is service-connected for PTSD at 70% and tinnitus at 10%. The primary issue is whether OSA is secondary to these service-connected conditions. The Veteran submitted lay statements describing potential OSA symptoms during service and a private medical opinion from Dr. MS. The VA examiner provided a negative opinion for direct service connection, attributing OSA to age and weight, and did not address secondary aggravation. Dr. MS, a highly qualified physician, opined that the Veteran's PTSD and tinnitus aggravated his OSA by causing fragmented sleep, a known OSA aggravator. The Board found Dr. MS's opinion thorough and well-reasoned, assigning it high probative value. Considering the approximate balance of evidence, including the lay statements and the positive private opinion, and affording the Veteran the benefit of the doubt, the Board found that the service-connected PTSD and tinnitus aggravated the OSA. Therefore, service connection for OSA, secondary to PTSD and tinnitus, was granted.

Rationale

Current diagnosis of OSA established.; Service connection for PTSD and tinnitus established.; Private medical opinion found PTSD and tinnitus aggravated OSA via fragmented sleep.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210727-174786

Full Decision Text

Citation Nr: A26036777
Decision Date: 04/21/26 Archive Date: 04/21/26

DOCKET NO. 210727-174786
DATE: April 21, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea (OSA), secondary to service-connected post-traumatic stress disorder (PTSD) and tinnitus, is granted.

FINDING OF FACT

The evidence is in approximate balance that the Veteran's OSA was aggravated by his PTSD and tinnitus.

CONCLUSION OF LAW

Resolving doubt in the Veteran's favor, the criteria for entitlement to service connection for OSA, secondary to PTSD and tinnitus, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served honorably in the United States Army from September 1989 through October 1992. He had over two years of foreign service, deployed to Southwest Asia, and was awarded the Air Assault Badge, Southwest Asia Service Medal w/3rd Bronze Star, Kuwait Liberation Medal, and others.

Introduction

This matter comes before the Board of Veterans' Appeals (Board) on the Veteran's appeal of a July 2020 higher-level review rating decision, which reviewed a February 2020 rating decision. Both decisions were issued by the Department of Veterans Affairs (VA) Regional Office, the Agency of Original Jurisdiction (AOJ). Both decisions denied the Veteran's claim of entitlement to service connection for OSA. The Veteran submitted a July 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), appealing the AOJ's denial to the Board. There he elected the Hearing docket, requesting a hearing before a member of the Board. In August 2022, the Veteran withdrew his hearing request. See August 2022 Correspondence.

Evidentiary Windows

Because the Veteran elected a hearing and subsequently withdrew his hearing request, the Board may only consider the evidence of record at the time of the February 2020 rating decision (which was subject to higher level review), as well as any evidence submitted by the Veteran within 90 days following receipt of the withdrawal of the hearing request. 38 C.F.R. § 20.302(b). If any evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to receipt of the withdrawal, or (2) more than 90 days following receipt of the withdrawal, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(b), 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 the 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.

New and Relevant Evidence

As the Veteran's claim was decided after February 2019, it is adjudicated under the Appeals Modernization Act (AMA) framework. Under the AMA, when new and relevant evidence is presented or secured with respect to a veteran's supplemental claim, the AOJ will readjudicate the claim taking into consideration all of the evidence of record. 38 C.F.R. § 3.2501.

"New" evidence is evidence not previously part of the actual record before agency adjudicators. 38 C.F.R. § 3.2501(a)(1). "Relevant" evidence is information that tends to prove or disprove a matter at issue in a claim, including evidence that raises a theory of entitlement that was not previously addressed. 38 C.F.R. § 3.2501(a)(2).

Here, the Veteran submitted an expert medical opinion which concluded that the Veteran's OSA was aggravated by his service-connected PTSD and tinnitus, in addition to lay statements from witnesses who described observing potential OSA-related sleep symptoms during service. New and relevant evidence was received by VA and the Board will proceed to adjudicate the Veteran's substantive claim.

Legal Criteria

Service Connection

Generally, service connection (which is a prerequisite to entitlement to disability compensation) will be granted if it is shown that a veteran suffers from a disability resulting from an injury suffered or disease contracted in the line of duty
including evidence that raises a theory of entitlement that was not previously addressed. 38 C.F.R. § 3.2501(a)(2).

Legal Criteria

Service Connection

Generally, service connection (which is a prerequisite to entitlement to disability compensation) will be granted if it is shown that a veteran suffers from a disability resulting from an injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303.

If the injury or disease is diagnosed after discharge from service, service connection may also be granted when all the evidence establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). A veteran bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107; Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009); Cromer v. Nicholson, 455 F.3d 1346 (Fed. Cir. 2006).

In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a current 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).

Establishing service connection on a secondary basis requires sufficient evidence 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 (a)-(b). 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 not caused by a service-connected disability would be less severe were it not for a service-connected disability. Id. For example, secondary aggravation may be established where the natural progression of the non-service connected disability could have been arrested or improved but for the service-connected disability. Id.

Evidence Assessment

The Board, in its role as factfinder, determines the weight and credibility of evidence. Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001); 38 U.S.C. § 7104(a). The Board may interpret evidence and make reasonable inferences from it. Evans v. McDonald, 27 Vet. App. 180, 187 (2014). Further, as factfinder, the Board has wide latitude and discretion in its evaluation of the evidence; its assignment of probative weight, credibility determinations, interpretations, and ultimate conclusions are subject to review under the deferential clearly erroneous standard. 38 U.S.C. § 7261(a)(4).

In making determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on matters which they have personal knowledge of, such as the onset and continuity of symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 131
)(4).

In order to be adequate for adjudicative purposes (and thus entitled to probative value), a medical opinion must contain not only clear conclusions with supporting data, but also a well-reasoned explanation connecting the two. Nieves-Rodrigues v. Peake, 22 Vet. App. 295 (2008). An examiner must consider all pertinent evidence of record, including lay evidence. Id.; Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Dalton v. Nicholson, 21 Vet. App. 23 (2007). When determining whether secondary service connection exists, a medical opinion must determine whether the claimed condition was either caused or aggravated by the service-connected condition(s). 38 U.S.C. § 1110; El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Naturally, the Board may reject a medical opinion as inadequate when it is based on facts contradicted by the record. Swann v. Brown, 5 Vet. App. 229, 233 (1993); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993).

The benefit of the doubt doctrine, codified at 38 U.S.C. § 5107(b), is a unique standard of proof in the American jurisprudence; "the nation, 'in recognition of our debt to our veterans' has 'taken upon itself the risk of error . . .' in awarding such benefits." Wise v. Shinseki, 26 Vet. App. 517, 531 (2014). Therefore, when there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of a matter before VA, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 4.3. However, the benefit-of-the-doubt rule does not apply when the evidence persuasively favors one side or the other. Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021).

Evidence, Analysis, and Conclusion

The Veteran provided evidence that his service-connected PTSD and tinnitus aggravated the severity of his OSA. See August 2022 Private Medical Opinion. For the reasons outlined below, the Board will afford the Veteran the benefit of the doubt and award service connection under that theory of entitlement.

First, the AOJ made the favorable finding that the Veteran had a current diagnosis for OSA. See July 2020 Rating Decision Narrative. Favorable findings are generally binding on the Board absent clear and unmistakable error. 38 C.F.R. § 3.104. There was no indication this finding constitutes a clear and unmistakable error; the first element of secondary service connection, a current diagnosis, has been met.

Next, the Veteran is service connected for both PTSD (rated as 70 percent disabling) and tinnitus (rated as 10 percent disabling). See, e.g., March 2022 Rating Decision Narrative. Again, favorable findings are generally binding on the Board. There was no indication of a clear and unmistakable error; the second element of secondary service connection, a primary service connected condition or conditions, has been satisfied.

Finally, the Board must determine whether the Veteran's PTSD and tinnitus caused or aggravated his OSA. Determining etiological relationships between auditory, mental health, and sleep respiratory conditions requires medical expertise. The Board acknowledges the lay statements from the Veteran's ex-spouse and a fellow servicemember and assigned them some probative value for their descriptions
(rated as 70 percent disabling) and tinnitus (rated as 10 percent disabling). See, e.g., March 2022 Rating Decision Narrative. Again, favorable findings are generally binding on the Board. There was no indication of a clear and unmistakable error; the second element of secondary service connection, a primary service connected condition or conditions, has been satisfied.

Finally, the Board must determine whether the Veteran's PTSD and tinnitus caused or aggravated his OSA. Determining etiological relationships between auditory, mental health, and sleep respiratory conditions requires medical expertise. The Board acknowledges the lay statements from the Veteran's ex-spouse and a fellow servicemember and assigned them some probative value for their descriptions of potential OSA-related symptomology. See August 2022 Lay Statement of SM; August 2022 Lay Statement of DP. However, because neither witness has been shown to possess any specialized medical expertise, the Board will focus its discussion on the expert medical opinions of record.

There is a VA medical opinion from August 2013 offering a negative opinion on direct service connection, as well as the more recent positive secondary aggravation opinion of Dr. MS, which was noted above. See August 2013 VA Medical Opinion.

The August 2013 VA Medical Opinion provided the negative opinion for direct service connection. There, the examiner concluded that the Veteran's OSA was less likely than not related to his military service. The examiner explained OSA is caused by the physical collapse of the airway which in turn impairs breathing, and suggested that the Veteran's age and weight were the more likely causes of his OSA, especially as there were no indication of OSA symptoms notated in the Veteran's service treatment records. The examiner did not provide an opinion on secondary service connection, and there were no other VA examinations offering opinions on secondary service connection.

The Board is left to consider the August 2022 private medical opinion of Dr. MS, MD. Dr. MS provided a brief summary of his impressive medical education and career, which includes matriculation at a top medical school, professorship, and long clinical practice. In his opinion, Dr. MS provided extensive summary and commentary on the Veteran's medical history with citation to the relevant record and to supporting medical literature. Dr. MS explained that both PTSD and tinnitus interfere with a patient's sleep cycle, resulting in fragmented sleep. Fragmented sleep is a known aggravator of OSA. The Board found Dr. MS's opinion to be thorough and well-reasoned; affording his conclusion that the Veteran's PTSD and tinnitus caused fragmented sleep, which in turn "substantially aggravated" his OSA, high probative value.

Because the Board assigned the only medical opinion offering a conclusion on secondary service connection high probative value, the evidence is at least in approximate balance that the Veteran's service-connected PTSD and tinnitus aggravated his OSA. This conclusion is strengthened by the supporting lay statement from a fellow soldier describing the Veteran's gasping during sleep becoming "particularly noticeable" after return from deployment and a VA mental health examination report which identified chronic sleep impairment as a symptom of the Veteran's acquired psychiatric disorder. See August 2022 Lay Statement of DP; August 2012 Mental Disorders (except PTSD and Eating Disorders) Examination (identifying chronic sleep impairment as part of the Veteran's psychiatric symptomology).

Therefore, because the evidence was at least in approximate balance and after affording the Veteran the benefit of the doubt, the Board finds that the third element of secondary service connection, causation or aggravation of the Veteran's OSA by his service-connected conditions, has been met.

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The three elements of secondary service connection have been satisfied by the evidence before the Board; accordingly, the Veteran's claim of entitlement to service connection for OSA is granted.

Colleen M. Glaser-Allen

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. Stanley

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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