SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

MICHAEL LANE · 2026 · Case ID: A26040250

MIXED

Summary

The Veteran served on active duty from August 1986 to December 1992. This case involves the Veteran's appeal from May 2021 rating decisions concerning obstructive sleep apnea, gastroesophageal reflux disease (GERD), and migraine headaches. The Veteran sought service connection for obstructive sleep apnea as secondary to his service-connected PTSD, and for GERD and migraine headaches as secondary to PTSD, citing medication, stress, and weight gain. The Board granted service connection for obstructive sleep apnea, finding that the Veteran's PTSD, through weight gain as an intermediate step, proximately caused the sleep apnea. This decision was based on resolving reasonable doubt in the Veteran's favor, as the VA examination was deemed inadequate for failing to address the theory of causation and the potential role of obesity. The Board found the private medical opinion from Dr. Patel, while diminished in weight due to lack of detailed rationale, supported the claim. The claims for GERD and migraine headaches were remanded. The Board found the VA examinations for these conditions inadequate because they did not address the Veteran's specific contentions of secondary causation from PTSD, medication, stress, or potential weight gain, nor did they adequately address aggravation. The Board noted that the provided medical literature did not sufficiently support the claimed causal link for GERD and headaches without further individual analysis.

Rationale

VA examination found less likely than not related to PTSD; Examiner provided generic, conclusory rationale; Examiner failed to consider Veteran's contentions and evidence; Examiner failed to consider obesity as intermediate step; Private opinion from Dr. Patel received prior to VA exam; Resolving reasonable doubt in Veteran's favor; Evidence in relative balance for and against claim

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210628-168575

Full Decision Text

Citation Nr: A26040250
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 210628-168575
DATE: April 29, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea is granted.

REMANDED

Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded.

Entitlement to service connection for migraine headaches is remanded.

FINDING OF FACT

Resolving reasonable doubt in the Veteran's favor, the evidence establishes that his current sleep apnea is proximately due to his service-connected posttraumatic stress disorder (PTSD), with obesity acting as an intermediate step of causation.

CONCLUSION OF LAW

The criteria for service connection for sleep apnea as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from August 1986 to December 1992.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2021 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO), which is the agency of original jurisdiction (AOJ).

In a June 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 Veteran Law Judge in March 2025. A transcript of the hearing has been included in the evidentiary record.

Therefore, the Board may only consider the evidence of record at the time of the May 2021 AOJ rating decisions on appeal, 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 AOJ issued the decision on appeal 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 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.

Service Connection

The Veteran is seeking to establish service connection for obstructive sleep apnea as secondary to his service-connected PTSD. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995).

With regard to obesity, VA's General Counsel has held that obesity may act as an intermediate step 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). VA. Gen. Coun. Prec. 1-2017 (Jan. 6, 2017). In order to establish service connection on this basis, three criteria must be met: (1) the service-connected disease or injury must have caused the veteran to become obese; (2) the obesity as a result of the service connected disability must be a substantial factor in causing the disability for which service connection is sought; and (3) whether the disability for which service connection is sought would not have occurred but for obesity caused by the service connected disease or injury. Id. However, obesity itself is not a disease for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore "may not be service connected on a direct basis." Id.

As an initial matter, the Board notes that the Veteran has a current diagnosis for obstructive sleep apnea and is currently service connected for PTSD. These are favorable findings in the May 2021 rating decision on appeal and are binding on the Board. Thus, the question before the Board is whether the Veteran's sleep apnea was caused or aggravated by his PTSD.

The Veteran contends that his sleep apnea is related to his service-connected PTSD. In April 2021, prior to the rating decision on appeal, the Veteran submitted a private medical opinion from Dr. Patel opining that he has experienced weight gain due to medication from service-connected PTSD, as well as stress eating, which in turn caused his sleep apnea. The medical evidence reflects that the Veteran's body mass index is over 30, indicating obesity.

The Board finds that the April 2021 private medical opinion is adequate for adjudication of the sleep apnea claim as obesity is a well-known risk factor for developing obstructive sleep apnea. There is no evidence that the private physician is not competent or credible, and as the reports are based on the Veteran's statements, treatment history, and the treating physician's conclusions are based on clinical findings of the Veteran's treatment records, and the Board finds the opinion is entitled probative weight, although this weight is diminished due to a lack of rationale thoroughly explaining its conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 305 (2008) (most of the probative value of a medical opinion comes from its reasoning).

The Veteran was provided with a May 2021 VA examination for sleep apnea. The examiner opined that the Veteran's diagnosed sleep apnea was less likely than not due to service and provided the following rationale: "sleep apnea is less likely than not proximately due to or the result of PTSD. Obstructive sleep apnea is the result of obstruction of the upper airway. PTSD can affect sleep and lead to disruptive sleep and insomnia, but not obstruction of the upper airways. Therefore, it is less likely than not that PTSD is the underlying cause of his diagnosis of obstructive sleep apnea. Alcohol blocks REM sleep, and will lead to individuals feeling groggy and not rested with excessive use. This however cannot obstruct the upper airway and cause sleep apnea. Therefore a nexus cannot be established for PTSD, alcohol causing sleep apnea."

During the Board hearing, the Veteran testified that during service he experienced snoring during service. He reported being in chronic pain and had significant sleeping issues, which he believed that his PTSD and alcohol use contributed to sleep apnea, and eventually he was prescribed with a CPAP machine. He also reported that service-connected disabilities like diabetes and neuropathy resulted in a more sedentary lifestyle, leading to weight gain. The Veteran's representative noted that the VA opinion on sleep apnea did not address this theory of causation.

Following a review of the claims file, the Board finds the evidence of record is in relative balance for and against the claim. While the May 2021 VA examination did not find a nexus between the Veteran's sleep apnea and service, to include the service-connected PTSD and alcohol use disorder, the examiner provided generic, conclusory rationale that failed to consider the Veteran's contentions and the evidence of record. Additionally, the examiner failed to consider whether the Veteran's PTSD resulted in obesity, which acted as an intermediate step towards the development of obstructive sleep apnea, though it was clearly raised by the record given the private opinion from Dr. Patel had been received by VA in April 2021, prior to the May
of causation.

Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that the three elements to establish obesity as an intermediate step for the purposes of entitlement to service connection for sleep apnea as secondary to the Veteran's PTSD have been met.

In view of the totality of the evidence, including the medical opinions of record, the Board finds the evidence is in relative balance for and against the claim of service connection. Particularly, while conflicting medical conclusions are of record, there is sufficient evidence of record to favorably adjudicate the claim in view of the benefit of the doubt doctrine and the probative evidence of record. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Consequently, the Board finds that resolving reasonable doubt in the Veteran's favor, service connection for sleep apnea as secondary PTSD is warranted. See 38 U.S.C. § 5107(b), 38 C.F.R. §3.102. Accordingly, the appeal for service connection for sleep apnea is granted.

REASONS FOR REMAND

The Veteran contends that he is entitled to service connection for GERD and migraine headaches. Specifically, in two different April 2021 VA Form 21-526EZ Application for Disability Compensation and Related Benefits the Veteran asserted that his GERD was secondary to PTSD due medication, stress, depression and his headaches were secondary to PTSD with alcohol use disorder and related to prescription medication and stress, resulting in headaches occurring at least 5 times per month.

In April 2021, the Veteran submitted a private medical opinion from Dr. Patel that the Veteran's service-connected PTSD resulted in medication and stress eating that resulted in weight gain, which resulted in secondary GERD and headaches. No rationale was provided explaining this causal relationship and unlike with sleep apnea, where obesity is a well-known risk factor, the etiological relationship between obesity and GERD as well as headaches is unclear and requires a rationale providing medical support for its conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

The Board has considered the scientific article entitled "Is alcohol consumption associated with gastroesophageal disease" submitted by the Veteran during the evidentiary window after the Board hearing. However, it is general medical research that does not specifically discuss the Veteran's individual circumstances and is therefore inadequate. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (stating that a medical rational based solely on general medical literature without discussing the specific facts pertaining to a veteran's condition or individual circumstances is inadequate).

The Veteran was provided with VA examinations for GERD and headaches in May 2021. The Veteran was diagnosed with both GERD and migraine headaches. The examiner opined that the GERD was less likely than not related to service and provided the following rationale: "Military record reviewed as requested. This veteran's migraine headaches & GERD is not caused by nor due to his service connected PTSD with alcohol use disorder. Migraine headaches occur as a result of abnormal brain activity temporarily affecting nerve signals, chemicals and blood vessels in the brain. GERD is a digestive disease in which stomach acid or bile irritates the food pipe lining. Acid reflux and heartburn more than twice a week may indicate GERD. Symptoms include burning in the chest that usually occurs after eating and worsens when lying down. Treatment consist of medication such as antacids and proton pump inhibitors."

The Board finds that these opinions are inadequate as they do not address the Veteran's contentions regarding his PTSD secondarily causing his diagnosed GERD and migraine headaches due to prescribed medication and stress. Further, the Board finds that these VA opinions do not adequately discuss the issue of aggravation, as the rationale focused on descriptions of GERD and migraine headaches rather than addressing the potential etiological relationship with the Veteran's PTSD. The Court of Appeals for Veterans Claims has held
stomach acid or bile irritates the food pipe lining. Acid reflux and heartburn more than twice a week may indicate GERD. Symptoms include burning in the chest that usually occurs after eating and worsens when lying down. Treatment consist of medication such as antacids and proton pump inhibitors."

The Board finds that these opinions are inadequate as they do not address the Veteran's contentions regarding his PTSD secondarily causing his diagnosed GERD and migraine headaches due to prescribed medication and stress. Further, the Board finds that these VA opinions do not adequately discuss the issue of aggravation, as the rationale focused on descriptions of GERD and migraine headaches rather than addressing the potential etiological relationship with the Veteran's PTSD. The Court of Appeals for Veterans Claims has held that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b). El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013); see also Atencio v. O'Rourke, 30 Vet. App. 74 (2018) (finding that causation and aggravation are independent concepts and should have separate rationales).

When VA undertakes to obtain an examination, it must ensure that the examination and medical opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, remand is necessary to correct a pre-decisional error in the duty to assist. 38 C.F.R. § 20.802(a). Specifically, the Veteran has not received adequate VA medical opinions regarding the GERD and migraine headache service connection claims. Remand is therefore necessary to obtain addendum medical opinions which adequately address the issue of potential secondary causation by PTSD, to include obesity as an intermediate step in a causal chain.

The matters are REMANDED for the following action:

1. A copy of this remand and the claims file must be made available to and reviewed by the VA examiner prior to providing the requested addendum opinions. The need for a new VA examination is left to the discretion of the examiner.

Obtain an addendum opinion from an appropriate clinician regarding:

(a.) whether the Veteran's diagnosed GERD is at least as likely as due to service-connected PTSD with alcohol use disorder, to include medication, stress, and depression associated with PTSD.

(b.) Is it at least as likely as not (i.e., evidence in approximate balance or greater) that the Veteran's GERD was aggravated by his PTSD with alcohol use disorder, to include potential weight gain? The clinician is advised that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation; the reasoning behind an aggravation opinion must be different or independent from the reasoning behind the causation opinions of record.

If aggravation is found, the clinician should identify a baseline (the degree of disability prior to aggravation).

The April 2021 private medical opinion by Dr. Patel should be considered and addressed in the medical opinion.

The clinician should provide a complete rationale for any medical opinions provided. If any requested opinion cannot be provided without resorting to mere speculation, then the examiner should explain.

2. Obtain an addendum opinion from an appropriate clinician regarding:

(a.) whether the Veteran's diagnosed migraine headaches are at least as likely as not related to or due to service-connected PTSD, to include prescription medication and stress.

(b.) Is it at least as likely as not (i.e., evidence in approximate balance or greater) that the Veteran's migraine headaches was aggravated by his PTSD? The clinician is advised that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation; the reasoning behind an aggravation opinion must be different or independent from the reasoning behind the causation opinions of record.

If aggravation is found, the clinician should identify a baseline (the degree of disability prior to aggravation).

(c.) Notwithstanding the prior answers, provide an opinion as to whether it is at least as likely as not that (1) the Veteran's service-connected PTSD caused him to become obese through prescribed medication and/or stress eating; (2) if so, whether the resulting obesity as was
's migraine headaches was aggravated by his PTSD? The clinician is advised that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation; the reasoning behind an aggravation opinion must be different or independent from the reasoning behind the causation opinions of record.

If aggravation is found, the clinician should identify a baseline (the degree of disability prior to aggravation).

The April 2021 private medical opinion by Dr. Patel should be considered and addressed in the medical opinion.

MICHAEL LANE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board N. Keogh, 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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