HYPERTENSION

Summary

The Veteran, who served from April 1982 to April 1986, appeals the denial of service connection for central sleep apnea and the Board has added entitlement to service connection for hypertension. The Veteran claimed sleep apnea due to Camp Lejeune water exposure and as secondary to a psychiatric disorder. The agency of original jurisdiction (AOJ) denied the sleep apnea claim in November 2024. The Board reviewed evidence of record up to that AOJ decision. Service treatment records were silent regarding sleep apnea, and the separation examination was normal. A June 2023 VA exam provided a negative nexus opinion, incorrectly stating the Veteran served in Southwest Asia and that sleep apnea is not presumptive for that service, and attributing the condition to a stroke unrelated to service. An August 2024 VA exam also provided a negative nexus opinion, noting medical literature is silent on toxic exposure causing sleep apnea and that strokes are a primary cause, which the Veteran experienced. However, the Board found this opinion inadequate as it did not address potential links between toxic exposure and strokes. A January 2026 private medical opinion from Dr. M.R. provided a positive nexus, linking hypertension and stroke to Camp Lejeune exposure, and central sleep apnea to the stroke. The Board found this private opinion persuasive, noting the DeLisio duty to investigate secondary conditions. Resolving doubt in the Veteran's favor, the Board found hypertension associated with service and granted service connection. It also found central sleep apnea related to service, granting service connection.

Rationale

Evidence in approximate balance; Resolved doubt in Veteran's favor; Private medical opinion linked to Camp Lejeune exposure

Full Decision Text

Citation Nr: A26037116
Decision Date: 04/21/26	Archive Date: 04/21/26

DOCKET NO. 251106-605290
DATE: April 21, 2026

ORDER

Entitlement to service connection for hypertension, including stroke residuals, is granted.

Entitlement to service connection for central sleep apnea is granted.

FINDINGS OF FACT

1. The evidence is at least in approximate balance as to whether the Veteran's hypertension is related to service.

2. The Veteran's central sleep apnea was caused by service-connected hypertension.

CONCLUSIONS OF LAW

1. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303; DeLisio v. Shinseki, 25 Vet. App. 45, 54 (2011).

2. The criteria for service connection for central sleep apnea have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from April 1982 to April 1986.

The rating decision on appeal was issued in November 2024 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In July 2024, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of a claim of entitlement to service connection for sleep apnea that was previously addressed in a July 2023 rating decision.  In November 2024, the agency of original jurisdiction (AOJ) issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision.

In the November 6, 2025, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the November 2024 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a supplemental claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a supplemental claim are included with this decision.

As a final preliminary matter, the Board has added entitlement to service connection for hypertension as an issue on appeal. Review of the central sleep apnea claim raises the issue of hypertension as a service-connected disease, and it is reasonably encompassed by the service connection claim for central sleep apnea. DeLisio v. Shinseki, 25 Vet. App. 45, 54 (2011).

Service Connection

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service.  38 C.F.R. § 1110; 38 C.F.R. § 3.303.

Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Such secondary service connection is also warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(b).

Establishing service connection on a secondary basis requires evidence (1) that a current disability exists, and (2) that the current disability was either (a) caused by or
 initially diagnosed after service.  38 C.F.R. § 1110; 38 C.F.R. § 3.303.

Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Such secondary service connection is also warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(b).

Establishing service connection on a secondary basis requires evidence (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; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding that "but for" causation or aggravation is sufficient to show entitlement to secondary service connection).

In DeLisio v. Shinseki, 25 Vet. App. 45, 54-55 (2011), the United States Court of Appeals for Veterans Claims (Court) stated that when a claim is pending and information obtained reasonably indicates that the claimed condition is caused by a disease or disability that may be associated with service, VA must investigate the possibility of secondary service connection; and, if that causal disease or disability is, in fact, related to service, the pending claim reasonably encompasses a claim for benefits for the causal disease or disability, such that no separate filing is necessary to initiate a claim for benefits for the causal disease or disability. Indeed, a claimant need not file a claim for benefits for the precise medical cause of their condition, as the law does not expect the claimant to have the medical or legal expertise to file a claim requesting benefits for each technical disability in the causal chain of disabilities that comprises his condition. Id.; see also Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).

Here, the Veteran contends that he has sleep apnea due to exposure to contaminated water at Camp Lejeune and as secondary to his service-connected psychiatric disorder, which is currently diagnosed as unspecified anxiety disorder and previously claimed as posttraumatic stress disorder (PTSD).  See May 2023 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits.

The Veteran is diagnosed with central sleep apnea.  See August 2024 VA examination report.  Additionally, the Board notes the AOJ made a favorable finding in the November 2024 rating decision that the Veteran had presumed toxic exposure to contaminated water at Camp Lejeune.  This finding is binding.  See generally 38 C.F.R. § 3.104.  Accordingly, the key inquiry is whether the current condition is related to the Veteran's exposure to contaminated water at Camp Lejeune and whether the condition is due to or the result of a service-connected disease or injury, as alleged.

The available service treatment records are silent for complaints of and treatment for sleep apnea.  Additionally, the Veteran's March 1986 separation examination noted a normal clinical evaluation of the nose, sinuses, mouth and throat, and lungs and chest.  

In a June 2023 VA medical opinion, the examiner provided a negative nexus opinion for the Veteran's claimed sleep apnea.  As rationale, the examiner noted that "sleep apnea is not considered to be a presumptive condition based on SW Asia service."  The examiner noted that the Veteran "has a condition of Cheyne-Stokes respiration which leads to his central sleep apnea. This condition is associated with strokes (which the Veteran has had and is unrelated to military service)."  However, the Board notes the opinion is inadequate to the extent that it is based on an inaccurate factual premise-that the Veteran served in Southwest Asia and that his claim for service connection relates to exposures in Southwest Asia.

In an August 2024 VA medical opinion, the examiner provided a negative nexus opinion for the Veteran's claimed sleep apnea with regard to his conceded exposure to contaminated water at Camp Lejeune.  As rationale, the examiner noted "[m]edical literature is silent for evidence that the Veteran's toxic risk exposures caused his sleep apnea."  The examiner went on to note that the Veteran was diagnosed with central sleep apnea after having a stroke, and that "[m]edical literature shows that strokes are one of the main causes
, the Board notes the opinion is inadequate to the extent that it is based on an inaccurate factual premise-that the Veteran served in Southwest Asia and that his claim for service connection relates to exposures in Southwest Asia.

In an August 2024 VA medical opinion, the examiner provided a negative nexus opinion for the Veteran's claimed sleep apnea with regard to his conceded exposure to contaminated water at Camp Lejeune.  As rationale, the examiner noted "[m]edical literature is silent for evidence that the Veteran's toxic risk exposures caused his sleep apnea."  The examiner went on to note that the Veteran was diagnosed with central sleep apnea after having a stroke, and that "[m]edical literature shows that strokes are one of the main causes of central sleep apnea."  The examiner concluded that the Veteran's claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. Notably, the examiner did not provide an opinion as to whether any of the identified causes of sleep apnea are etiologically related to service, including in-service TERAs, and the AOJ did not request an addendum issue to address this matter prior to issuing the rating decision on appeal.

Additionally, the Veteran submitted the January 2026 medical opinion of Dr. M.R., who provided a positive nexus opinion for the Veteran's central sleep apnea.  In pertinent part, Dr. M.R. concluded that the Veteran's hypertension and stroke are at least as likely as not related to the Veteran's exposure to contaminated water at Camp Lejeune; and the Veteran's central sleep apnea is more likely than not related to his stroke, which is also consistent with VA findings. Dr. M.R. indicated that the medical literature supports a finding that there is an increased risk of hypertension associated with the toxins in the water at Camp Lejeune and that this exposure increases the risk of heart disease-related events, to include stroke. She reported that the Veteran's Cheyne-Stokes Respirations are associated with heart failure and stroke, Cheyne-Stokes Respiration or periodic breathing is often associated with heart failure and neurological disorders especially those involving the brainstem, and central sleep apnea developed as a result of the Veteran's stroke.

As indicated above, the Board has a duty to investigate whether a causal disease or disability is related to service, in order to determine whether the claimed condition is related secondary to service. DeLisio, 25 Vet. App. at 54. Here, the evidence shows that the Veteran's central sleep apnea is, at least in part, due to his hypertension. As such, following the holding in DeLisio, supra, the Board has a duty to determine if there is a causal relationship between the Veteran's hypertension and service. In this regard, the Board resolves any doubt in the Veteran's favor and relies on the rationalized private medical opinion in finding that the evidence supports such association. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Overall, the competent evidence of record indicates that the cause of the Veteran's central sleep apnea-hypertension-is associated with service; thus, the Board finds that the Veteran's central sleep apnea is related to service, and service connection is warranted. See DeLisio, 25 Vet. App. at 54; 38 C.F.R. §§ 3.303, 3.310. 

 

M. C. WILSON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Griggs

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.