ASTHMA

J. PARKER · 2026 · Case ID: A26038316

MIXED

Summary

The veteran, who served with multiple periods of service between March 1984 and August 2003, including service in Southwest Asia, appeals the denial of service connection for asthma, costochondritis, sleep apnea, and hypertension. The Board granted service connection for asthma, finding that the veteran's chronic cough and shortness of breath during service, coupled with his testimony of continued symptoms and a civilian diagnosis of asthma shortly after service, established an in-service incurrence and continuity of symptoms. The Board also granted service connection for costochondritis, finding that the veteran's exposure to TERAs and the requirement to wear heavy armor and carry weights during deployment constituted in-service events that caused the current condition, resolving doubt in the veteran's favor. Service connection for sleep apnea was denied, as the Board found the evidence weighed against direct in-service incurrence and that the veteran's service-connected psychiatric condition did not cause obesity or directly cause the sleep apnea, despite a private examiner's opinion suggesting a bidirectional relationship. Hypertension was also denied, as the evidence did not support an in-service incurrence, chronic symptoms during service, or manifestation within one year of service separation, and the veteran was not found to be obese, negating the secondary service connection theory via obesity. The Board noted missing service treatment records but found sufficient evidence for the granted claims.

Rationale

Current diagnosis of asthma; In-service symptoms of chronic cough and shortness of breath; Lay testimony of continued symptoms post-service; Evidence in relative equipoise, doubt resolved in veteran's favor

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210719-173053

Full Decision Text

Citation Nr: A26038316
Decision Date: 04/23/26 Archive Date: 04/23/26

DOCKET NO. 210719-173053
DATE: April 23, 2026

ORDER

Service connection for asthma is granted.

Service connection for costochondritis is granted.

Service connection for obstructive sleep apnea (sleep apnea) on a direct and secondary basis is denied.

Service connection for hypertension on a direct, chronic disease presumptive, and secondary basis is denied.

FINDINGS OF FACT

1. The evidence shows current diagnoses of asthma, costochondritis, sleep apnea, and hypertension.

2. The current asthma, costochondritis, sleep apnea, and hypertension are not medically unexplained chronic multi-symptom illnesses (MUCMIs).

3. Symptoms of asthma had their onset during service and have continued since service separation.

4. The evidence shows the Veteran was exposed to burn pit, oils to reduce blowing sand, jet fuels, barrels of human waste, and poor air quality due to the destruction of chemicals near the base (TERAs).

5. The TERAs and resultant severe coughing, plus the repetitive trauma due to wearing heavy gear and lifting heavy objects, caused the current costochondritis.

6. The in-service TERAs did not cause the sleep apnea.

7. The evidence does not show an in-service relevant respiratory event or symptoms attributable to sleep apnea, or sleep apnea symptoms during service.

8. Service connection has been established for a psychiatric disability.

9. The Veteran is not obese but is overweight.

10. The service-connected psychiatric disability did not cause or worsen in severity the current sleep apnea.

11. The in-service TERAs did not cause the current hypertension.

12. The evidence does not show in-service chronic symptoms of hypertension.

13. Symptoms of hypertension were not chronic during service, continuous since service separation, and did not manifest to a compensable degree within one year of service separation.

14. The service-connected psychiatric disability did not cause or worsen in severity the current hypertension.

CONCLUSIONS OF LAW

1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for asthma have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for costochondritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for service connection for sleep apnea on a direct and secondary basis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for service connection for hypertension on a direct, chronic disease presumptive, and secondary basis, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran, who is the appellant, had active service from March 1984 to March 1986, from January 1991 to January 1992, and from December 2002 to August 2003, which included service in Southwest Asia. The Veteran had additional periods of Reserve service.

The instant case is on appeal to the Board of Veterans' Appeals from an April 2020 Department of Veterans Affairs (VA) Regional Office (RO) rating decision that, in pertinent part, denied service connection for asthma, costochondritis, sleep apnea, and hypertension. The modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In September 2020, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of the April 2020 VA RO rating decision. In March 2021, the VA RO issued the HLR decision on appeal, which considered the evidence of record at the time of the prior April 2020 VA RO rating decision and denied the service connection claims.

In the July 19, 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held before the
review system, also known as the Appeals Modernization Act (AMA), applies.

In the July 19, 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held before the undersigned Veterans Law Judge (VLJ) in April 2025. A copy of the April 2025 Board hearing transcript has been associated with the claims file.

The Board may only consider the evidence of record at the time of the April 2020 VA RO rating decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the VA RO issued the decision, which was subsequently subject to higher-level review and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 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 or claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

There are some missing service treatment records (STRs) in this case. The claims file currently includes an enlistment Report of Medical Examination from December 1983, and copies of a Post-Deployment Health Assessment, Report of Medical History, and Report of Medical Examination from July 2003, but does not include any other records.

The VA RO has made multiple attempts to obtain missing records. The VA RO also informed the Veteran that the RO was having difficulty obtaining STRs. The VA RO stated that multiple requests had been made, asked if the Veteran had any STRs to provide, and suggested alternative ways of providing similar evidence if the Veteran did not have the STRs.

Despite these efforts, it appears that there still are records missing. In such situations, where treatment records are missing, the Board has a heightened duty to search for records and explain their efforts to that effect, a heightened obligation to explain its findings and conclusions, and a requirement to carefully consider the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all evidence that may be favorable to the veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). There is no presumption, either in favor of the claimant or against VA, arising from missing records.

At the April 2025 Board hearing, the representative raised the possibility of entitlement to a total disability rating for disability compensation purposes based on individual unemployability due to service-connected disabilities (TDIU). A TDIU was granted in October 2025, so the Board need not address it here. The Veteran has one year from the October 2025 rating decision to appeal the assigned effective date for TDIU.

Service Connection Legal Authority

The Veteran appeals for service connection for asthma, costochondritis, sleep apnea, and hypertension. With respect to each disability, the Veteran wrote that he was seeking service connection related to Southwest Asia because of a MUCMI, writing that asthma is a "respiratory disorder," sleep apnea is a "sleep disturbance," and hypertension and costochondritis are "neurological and psychological problems." See January 2018 Claim. All four conditions are clinically diagnosed, and with rare exceptions not applicable here the presence of a clinical diagnosis means that they are not MUCMIs. See 38 U.S.C. § 1117; 38 C.F.R. § 3.

Service Connection Legal Authority

Other specific contentions with respect to each disability are given in each section below.

Direct Service Connection

Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires competent evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service.

Chronic Disease Presumptive Service Connection

Hypertension is considered to be a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies to the appeal for service connection for hypertension. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For these reasons, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable. Id.

The United States Court of Appeals for Veterans Claims (Court or CAVC) has discussed two definitions of the word "chronic." One, as given in Dorland's Illustrated Medical Dictionary 359 (32d ed. 2012), is that a chronic disease is a disease "persisting over a long period of time." Additionally, VA's adjudicators consider a chronic disease to be one "of prolonged duration, producing incapacitating symptoms of varying degree that may undergo remission, and that is seldom entirely cured with all residuals of damage being completely eradicated." See Walker, 708 F.3d at 1336.

For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then, generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b).

Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1110, 1112, 1131; 38 C.F.R. §§ 3.307, 3.309(a).

Secondary Service Connection

Service connection may be granted for a disorder that is proximately due to or the result of a service-connected disability. An increase in severity of a non-service-connected disorder that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the non-service-connected condition, will be service-connected. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995).

The Role of Obesity

VA's General Counsel issued a precedential opinion concerning service connection based on obesity. See VAOPGCP
38 C.F.R. §§ 3.307, 3.309(a).

Secondary Service Connection

The Role of Obesity

VA's General Counsel issued a precedential opinion concerning service connection based on obesity. See VAOPGCPREC 1-2017. The opinion interprets, inter alia, that obesity may act as an "intermediate step" to establish proximate causation between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). Id. at 7-9. The Court has also held that obesity can act as an "intermediate step" to secondary service connection if the obesity aggravated (worsened in severity) the claimed service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300, 304 (2020).

In order to establish whether a service-connected disability proximately caused or aggravated a current disability through obesity, the adjudicator must determine: (1) whether the service-connected disability caused the veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing or aggravating the current disability; and (3) whether the current disability would not have occurred but for obesity caused or aggravated by the service-connected disability. See VAOPGCPREC 1-2017; Walsh, 32 Vet. App. at 304. If all questions are answered in the affirmative, then the current disability may be service connected on a secondary basis. Id.

1. Service Connection for Asthma is Granted.

The Veteran appeals for service connection for asthma, contending that in-service TERAs caused the current asthma. See April 2025 Board Hearing Transcript.

The evidence shows a current diagnosis of asthma. See, e.g., February 2019 VA Examination. Additionally, the VA RO issued a favorable finding that there was a current diagnosis of asthma. See April 2020 Rating Decision. The Board is bound by favorable findings of the VA RO in the absence of clear and convincing evidence to the contrary, which is not present here. 38 U.S.C. § 5104A; 38 C.F.R. § 3.104.

After a review of all the lay and medical evidence of record, the Board finds that the evidence is at least in relative equipoise on the question of whether there was an in-service onset of asthma, with symptoms such as shortness of breath and chronic coughing, such that service connection can be granted on a direct basis due to an in-service incurrence (38 C.F.R. § 3.303(d)). In a July 2003 Post-Deployment Health Assessment, the Veteran wrote that he had experienced a chronic cough during the appointment and at the time of the assessment, as well as difficulty breathing during the deployment. Similarly, in the July 2003 Report of Medical History, which is a document in which a veteran is required to report any health conditions that they are currently experiencing or had experienced previously, the Veteran checked "yes" to asthma or other breathing problems, being prescribed or using an inhaler, and chronic cough or cough at night.

The Veteran testified at the April 2025 Board hearing that, during and after service in Southwest Asia, he developed a cough and frequently coughed up sand and oil droplets, that he was told that he had asthma by a civilian doctor shortly after returning from the initial Southwest Asia deployment, and that symptoms of coughing had continued since service separation, even though the coughing up sand and oil ended approximately two years after service separation.

The Board will resolve reasonable doubt in favor of the Veteran to find that the symptoms of asthma, to include shortness of breath and chronic coughing, had their onset during service. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

The Board finds that the evidence is at least in relative equipoise on the question of whether the symptoms of asthma that started during service were continuous since service separation. The Veteran testified that he initially was coughing up sand and oil drops after service separation, but he also competently and credibly testified that the symptoms continued after service separation, leading to the diagnosis of asthma.
ing up sand and oil ended approximately two years after service separation.

The Board finds that the evidence is at least in relative equipoise on the question of whether the symptoms of asthma that started during service were continuous since service separation. The Veteran testified that he initially was coughing up sand and oil drops after service separation, but he also competently and credibly testified that the symptoms continued after service separation, leading to the diagnosis of asthma. The Board will resolve reasonable doubt in favor of the Veteran to find that the symptoms of asthma, to include shortness of breath and chronic coughing, have been continuous since service separation. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Given the above, the Board finds that there is some probative evidence in this case that supports a finding that the current asthma had its onset during service and that symptoms continued since service separation. For these reasons, the Board will grant the appeal for direct service connection for asthma.

2. Service Connection for Costochondritis is Granted.

The Veteran appeals for service connection for costochondritis, contending that carrying heavy weights and wearing heavy armor, as well as his exposure to burn pits during the deployments to Southwest Asia, led to current costochondritis. See March 2025 Private Opinion.

The evidence shows a current diagnosis of costochondritis. See, e.g., November 2018 VA Examination. Additionally, the VA RO issued a favorable finding that there was a current diagnosis of costochondritis. See April 2020 Rating Decision. The Board is bound by favorable findings of the VA RO in the absence of clear and convincing evidence to the contrary, which is not present here. 38 U.S.C. § 5104A; 38 C.F.R. § 3.104. Costochondritis, also known as costosternal or anterior chest wall syndrome, is inflammation of the cartilage that connects a rib to the breastbone (sternum). See https://www.mayoclinic.org/diseases-conditions/costochondritis/symptoms-causes/syc-20371175

The evidence shows that the Veteran served in Southwest Asia and was exposed to burn pits, oils to reduce blowing sand, jet fuels, barrels that disposed of human waste, and poor air quality due to the destruction of chemicals near the base (TERAs). See April 2025 Board Hearing Transcript; see also April 2020 Rating Decision (finding the Veteran served in Iraq). The evidence also shows that the Veteran would have been required to wear heavy armor and carry weights during deployment.

In November 2001, the Veteran was seen by a private treatment provider for sharp, stabbing left-sided chest pain that had lasted two to three days. The diagnosis was costochondritis. In a July 2003 Post-Deployment Health Assessment, the Veteran reported "yes" to chest pain or pressure. The Veteran also informed a private medical provider that the symptoms of chest wall pain dated back to February 1992, which would be shortly after service separation. See May 2025 Private Opinion. Symptoms were also reported in additional VA and private treatment records. See, e.g., February 2011 Private Treatment Record; September 2010 VA Treatment Record.

The Board will resolve reasonable doubt in favor of the Veteran to find that these two aspects of deployment, the TERAs and the heavy armor and weights, constitute in-service events, satisfying the service connection requirement of an injury, disease, or event in service, which is consistent with the Veteran's history of symptoms, diagnoses, and treatment. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

The Board finds that the evidence is at least in relative equipoise on the question of whether the in-service events, as supported by the medical records, caused the current costochondritis. In a May 2025 private opinion, the medical provider conducted an extensive review of all medical records and the claims file, reviewed the pertinent medical literature, wrote about the symptoms and etiology of the disability, and opined that the costochondritis was directly related to the military deployment activities, to include the heavy weights he would have been required to wear and carry, as well as the exposure to burn pits that led to a chronic cough. The Board will resolve reasonable doubt in favor of the Veteran to find that the in-service deployment events caused the current costochondritis. 38 U.S
in relative equipoise on the question of whether the in-service events, as supported by the medical records, caused the current costochondritis. In a May 2025 private opinion, the medical provider conducted an extensive review of all medical records and the claims file, reviewed the pertinent medical literature, wrote about the symptoms and etiology of the disability, and opined that the costochondritis was directly related to the military deployment activities, to include the heavy weights he would have been required to wear and carry, as well as the exposure to burn pits that led to a chronic cough. The Board will resolve reasonable doubt in favor of the Veteran to find that the in-service deployment events caused the current costochondritis. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

As there is probative evidence of a current disability of costochondritis, in-service events related to deployment, and a finding that the in-service events caused the current costochondritis, the criteria for direct service connection (38 C.F.R. § 3.303(a), (d)) have been met; therefore, the Board will grant the appeal for service connection for costochondritis.

3. Service Connection for Sleep Apnea is Denied.

The Veteran appeals for service connection for sleep apnea with two separate contentions. At the April 2025 Board hearing, the Veteran contended that decreased motivation from the service-connected psychiatric disability caused obesity, which led to the current obstructive sleep apnea, i.e., a theory of secondary service connection with obesity as an "intermediate step." 38 C.F.R. § 3.310. In the May 2025 private opinion, the examiner opined that the service-connected psychiatric disability proximately caused the obstructive sleep apnea, removing the intermediate step argument (secondary service connection under 38 C.F.R. § 3.310). Although the Veteran has only addressed these two theories of service connection, the Board will briefly address other potential theories of service connection.

First, the evidence shows a current disability of sleep apnea. The VA RO issued a favorable finding that there was a current diagnosis of sleep apnea. See April 2020 Rating Decision. The Board is bound by favorable findings of the VA RO in the absence of clear and convincing evidence to the contrary, which is not present here. 38 U.S.C. § 5104A; 38 C.F.R. § 3.104.

Concerning an in-service incurrence, the evidence shows that the Veteran experienced multiple TERAs due to service in Southwest Asia; however, on the nexus element, November 2018 and February 2019 VA examiners wrote that sleep apnea is a diagnosed condition that is not related to any exposures while serving in Southwest Asia. The examiners opined against direct service connection (38 C.F.R. §3.303(a), (d)) for sleep apnea as due to TERAs. As the VA examiners have medical training and are familiar with the pertinent medical evidence, the Board finds that the persuasive weight of the evidence shows that current sleep apnea is not etiologically related to the in-service TERAs.

With respect to any other in-service injury, disease, or event that could support a theory of direct service connection for sleep apnea, the Board finds that the evidence persuasively weighs against a finding of a relevant in-service incurrence. Although the Board acknowledges that the STRs are incomplete, the Veteran has never alleged that symptoms of sleep apnea like gasping for air, nonrestorative sleep, or daytime hypersomnolence were present during service. See April 2025 Board Hearing Transcript; January 2018 Claim.

Additionally, the Veteran did not report sleep disturbances or other symptom indicators in the July 2003 Report of Medical History. Although the Veteran reported in the July 2003 Post-Deployment Health Assessment that he experienced the symptom of "still feeling tired after sleeping," the Veteran reported that the symptom was present "during" deployment, rather than "during and now." In other words, although the symptom may have existed at one point during deployment, it was no longer present. Given this lay and medical evidence, the Board finds that the evidence persuasively weighs against a finding of an in-service incurrence, as required for direct service connection (38 C.F.R. § 3.303(a), (d).

Turning to the secondary service connection contention that the service-connected psychiatric disability caused the Veteran to become obese, which led to the current sleep apnea (38 C.F.R. § 3.310), the evidence shows that the Veteran is not obese. See VA Treatment Records; Private Treatment Records. The Board acknowledges the Veteran's testimony that the service-connected psychiatric disability
now." In other words, although the symptom may have existed at one point during deployment, it was no longer present. Given this lay and medical evidence, the Board finds that the evidence persuasively weighs against a finding of an in-service incurrence, as required for direct service connection (38 C.F.R. § 3.303(a), (d).

Turning to the secondary service connection contention that the service-connected psychiatric disability caused the Veteran to become obese, which led to the current sleep apnea (38 C.F.R. § 3.310), the evidence shows that the Veteran is not obese. See VA Treatment Records; Private Treatment Records. The Board acknowledges the Veteran's testimony that the service-connected psychiatric disability caused decreased motivation to exercise, causing the Veteran to gain forty pounds, which then fluctuated at times due to changing behaviors. See April 2025 Board Hearing Transcript. This testimony is supported by the VA treatment records, which show that, for example, the Veteran weighed 137 pounds in September 2003, 173 pounds in September 2010, and 137 pounds in July 2011. See VA Treatment Records.

Despite this weight gain, however, the Veteran has not become obese. As the theory of secondary service connection with obesity as an intermediate step (38 C.F.R. § 3.310) relies upon a veteran actually being obese, this theory of service connection is not substantiated.

Concerning the theory that the service-connected psychiatric disability caused the current sleep apnea, as contended by the May 2025 private examiner, the Board finds that the evidence persuasively weighs against a finding that the service-connected psychiatric disability caused the sleep apnea. While the May 2025 private examiner provided medical literature related to a relationship between the two disorders, the medical literature does not demonstrate a causal link, only an association. The private examiner wrote that psychiatric disabilities and sleep apnea have many overlapping symptoms like fatigue, daytime sleepiness, but this does not prove causation or aggravation. It merely hints at the difficulty for determining what disorder to treat and how to treat it, which the provided medical literature also discussed.

The private examiner then discussed medical literature related to a "bidirectional association" and/or a "colinear relationship." For example, longitudinal studies showed patients with obstructive sleep apnea had an increased risk of developing depression, but the private examiner acknowledged that less attention had been given to the opposite direction. The May 2025 private examiner wrote that there was evidence of a bidirectional relationship where each disease influences the development of the other, rather than that one disorder (psychiatric disability) caused the second (sleep apnea).

Similarly, the private examiner discussed a study in which the symptoms and characteristics when sleep apnea was associated with depression were male gender, snoring, excessive daytime sleepiness, lower insomnia complaints, the presence of metabolic syndrome, age greater than 50 years, body mass index greater than 30, ferritin greater than 300, CRP greater than 7, and duration of sleep greater than 8 hours. Although these may be risk factors as to when both are present, that again suggests an association between the two disabilities, rather than causation.

The primary study discussed in the May 2025 private opinion that hinted at a possible relationship found that the same reduced serotonin levels led to a sleep disturbance in depression and a reduction in muscle tone of the upper respiratory tract. This study acknowledged that the efficacy of antidepressants on sleep apnea had not been proven, but suggested certain psychiatric medications might help someone who had sleep apnea who was dealing with insomnia.

The Board finds that this study does not prove causation or aggravation; rather, it hints at the association between the two disabilities. The fact that the Veteran may have low serotonin levels, which is not proven in this case, and that psychiatric medication may improve the sleep apnea symptoms, does not establish that the depression itself caused or aggravated the low serotonin levels, which would then have to cause or aggravate the sleep apnea. Depression may be due to (in part) low serotonin levels, but the depression is not causing the low serotonin levels. The study demonstrates an association between symptoms or risk factors that may be attributable to both disabilities, which, again, may not even be present in the Veteran's case, but it does not establish that one caused or aggravated the other.

For these reasons, the Board finds that the evidence persuasively weighs against a finding that the service-connected psychiatric disability caused or aggravated the sleep apnea (38 C.F.R. § 3.310). Accordingly, service connection on a secondary basis must be denied. As service connection must be denied on a direct basis (38 C.F.R. § 3.303(a), (d)) and secondary
in part) low serotonin levels, but the depression is not causing the low serotonin levels. The study demonstrates an association between symptoms or risk factors that may be attributable to both disabilities, which, again, may not even be present in the Veteran's case, but it does not establish that one caused or aggravated the other.

4. Service Connection for Hypertension is Denied.

The Veteran appeals for service connection for hypertension with two separate contentions. At the April 2025 Board hearing, the Veteran contended that decreased motivation from the service-connected psychiatric disability caused obesity, which led to the current obstructive sleep apnea, i.e., a theory of secondary service connection with obesity as an "intermediate step." 38 C.F.R. § 3.310. In the May 2025 private opinion, the examiner opined that sleep apnea caused or aggravated the hypertension (secondary service connection under 38 C.F.R. § 3.310).

As with sleep apnea, although the Veteran has only addressed two theories of secondary service connection, the Board will briefly address other potential theories of service connection.

Concerning direct service connection, the evidence persuasively weighs against a finding of in-service symptoms of hypertension. The Veteran contended at the April 2025 Board hearing that he was told about elevated blood pressure once during service, but that the rest of the time he was told he did not have to worry. The Veteran is competent to relay what a medical provider told him. See, e.g., Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)

"Hypertension" refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and from 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland's Illustrated Medical Dictionary 909 (31st ed. 2007). For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater. The term "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1.

Similarly, as noted above, the Court has discussed two definitions of the word "chronic." One, as given in Dorland's Illustrated Medical Dictionary 359 (32d ed. 2012), is that a chronic disease is a disease "persisting over a long period of time." Additionally, VA's adjudicators consider a chronic disease to be one "of prolonged duration, producing incapacitating symptoms of varying degree that may undergo remission, and that is seldom entirely cured with all residuals of damage being completely eradicated." See Walker, 708 F.3d at 1336.

Notably, the one-time occurrence of a higher blood pressure reading is not an in-service incurrence related to hypertension, as required for direct service connection (38 C.F.R. § 3.303(a), (d)), as a one-time reading does not show persistent elevation or prolonged duration. Direct service connection must be denied.

The Board finds that the evidence persuasively weighs against a finding that symptoms of hypertension were chronic during service, continuous since service separation, or that they manifested to a compensable degree within one year of service separation. Concerning the question of whether there were chronic symptoms during service, as noted above, the one-time reading does not meet the requirements for symptoms of a "chronic disease." The possible hypertension symptom, even though it happened once during service, is not of prolonged duration and did not persist over a long period of time.

Concerning the questions of whether there were continuous post-service symptoms and whether symptoms manifested to a compensable degree within one year of service separation, the exact date of diagnosis is unclear. At the earliest and, therefore, most favorable, the Veteran reported that the hypertension was clinically diagnosed in approximately August 2011. See, e.g., VA Treatment Records; February 201
within one year of service separation. Concerning the question of whether there were chronic symptoms during service, as noted above, the one-time reading does not meet the requirements for symptoms of a "chronic disease." The possible hypertension symptom, even though it happened once during service, is not of prolonged duration and did not persist over a long period of time.

Even using the more favorable date, August 2011 is approximately eight years after service separation; therefore, the symptoms were not continuous and did not manifest to a compensable degree within one year of service separation. See also June 2006 VA Treatment Record (blood pressure reading of 127/80); July 2011 VA Treatment Record (blood pressure reading of 122/74). Given the findings above, service connection on a chronic disease presumptive basis (38 U.S.C. § 1112 and 38 C.F.R. § 3.303(b)) must be denied.

With respect to the contention that the service-connected psychiatric disability caused obesity that caused hypertension (38 C.F.R. § 3.310), which was raised at the April 2025 Board hearing, the evidence persuasively weighs against a finding that the Veteran is obese. This fact impacts the analysis for the reasons above and results in a denial of service connection under this theory.

The May 2025 private examiner opined that the sleep apnea caused or aggravated the hypertension. As this Board decision denies service connection for sleep apnea for the reasons given above, this theory of secondary service connection (38 C.F.R. § 3.310) must fail. Without a service-connected primary disability, service connection for an alleged secondary disability cannot be granted as a matter of law.

As service connection must be denied on a direct basis (38 C.F.R. § 3.303(a), (d)), a chronic disease presumptive basis (38 U.S.C. § 1112 and 38 C.F.R. § 3.303(b)), and secondary basis (38 C.F.R. § 3.310), the appeal for service connection for hypertension must be denied.

J. PARKER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Smith, Associate 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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