SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

S. HENEKS · 2026 · Case ID: A26040343

GRANTED

Summary

The Veteran, who served from October 1992 to August 2000 and May 2003 to December 2015, including a deployment to Afghanistan in 2011, appeals the denial of service connection for obstructive sleep apnea (OSA). The Veteran contends OSA was caused by his military service, citing symptoms like difficulty sleeping, snoring, irritability, and brain fog that began after his Afghanistan deployment. Alternatively, he claims OSA is secondary to his service-connected PTSD with depressive symptoms and cervical spine spondylosis. The Board reviewed evidence including service records, VA examinations, and private medical opinions. Service treatment records were silent on sleep issues until a November 2015 VA examination for PTSD, which noted chronic sleep impairment. However, the Veteran's private pulmonologist diagnosed severe OSA in December 2016, noting it could be present for years before diagnosis. A private physician's assistant in August 2024 opined that the Veteran's mental health and orthopedic conditions likely contributed to his significant weight gain, which in turn increased his risk of OSA. Resolving reasonable doubt in the Veteran's favor, the Board found OSA causally related to service, potentially through obesity as an intermediate step from his service-connected conditions. Service connection for OSA was granted.

Rationale

Resolving reasonable doubt in Veteran's favor; OSA causally or etiologically related to service; Obesity as intermediate step from service-connected disabilities

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210419-153705

Full Decision Text

Citation Nr: A26040343
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 210419-153705
DATE: April 29, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea (OSA) is granted.

FINDING OF FACT

Resolving reasonable doubt in the Veteran's favor, his diagnosed OSA has been shown to be causally or etiologically related to service.

CONCLUSION OF LAW

The criteria for entitlement to service connection for OSA have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from October 1992 to August 2000 and from May 2003 to December 2015.

This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2021 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

In the April 19, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on July 29, 2024.

Therefore, the Board may only consider the evidence of record at the time of the April 2021 agency of original jurisdiction (AOJ) decision 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.

The Board notes that in April 2021, medical articles in support of the Veteran's claim were associated with the claims file in conjunction with his April 2021 VA Form 10182. However, the Board is unable to consider this as the Veteran chose the Hearing docket. See April 2021 Correspondence.

Entitlement to service connection for OSA.

The Veteran contends that his diagnosed OSA was caused by his military service, specifically following his deployment to Afghanistan in 2011. He reported that not long after his deployment he developed some of the symptoms of OSA. He had great difficulty sleeping, to the point where he fell asleep driving the family vehicle, fell asleep at his desk at work, had to sleep on the couch because of his snoring/breathing, was extremely irritable, and had brain fog. Alternatively, the Veteran believes that his OSA could be secondary to his service-connected posttraumatic stress disorder with depressive symptoms (PTSD) and/or spondylosis with degenerative arthritis of the cervical spine (cervical spine). See July 2024 Hearing Transcript.

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; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); 38 C.F.R. § 3.303.

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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) prox
of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); 38 C.F.R. § 3.303.

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b).

The VA General Counsel states in an opinion that obesity is not a disease for service connection purposes. See VAOPGCPREC 1-2017 (Jan 6, 2017). Nonetheless, obesity may be an intermittent step between a service-connected disability and a current disability that may be service connected on a secondary basis. To grant service connection, the adjudicators would have to resolve the following issues: (1) whether a service-connected disability caused a veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability for which a Veteran is seeking service connection; and (3) whether the current disability for which a veteran is seeking service connection would not have occurred but for the obesity caused by the service-connected disability. Id. at 9-10.

In Walsh v. Wilkie, 32 Vet. App. 300 (2020), the Court of Appeals for Veterans Claims (Court) held VAOPGCPREC 1-2017 not only applies when a service-connected disability causes obesity, but also when a service-connected disability aggravates obesity. When raised by the record, the Board must consider whether obesity was caused or aggravated by a service-connected disability, consistent with 38 C.F.R. § 3.310(b).

It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38?C.F.R. §?3.102. The claimant is entitled to the benefit of the doubt when the evidence is in "approximate" balance (i.e., "nearly equal)" but does not require that the evidence be in exact equipoise. Lynch v. McDonough, 999 F.3d 1391, 1394?(Fed. Cir. 2021).

In pertinent part, the Veteran is service connected for PTSD with depressive symptoms and for his cervical spine. Additionally, the Veteran is also service connected for multiple other musculoskeletal disabilities, to include his lumbar spine, bilateral knee, bilateral shoulder, and left lower extremity radiculopathy. See April 2021 Rating Decision - Codesheet.

A November 2000 body fat content worksheet noted the Veteran was 72 inches tall and weighed 207 pounds. The Veteran's final Officer Evaluation Report (OER) as a part time member of the National Guard in February 2003 showed the Veteran was 72 inches tall and weight 205 pounds. See March 2023 DPRIS Response.

In the January 2006 report of medical history, the Veteran affirmatively marked "no" to frequent trouble sleeping. In the accompanying January 2006 report of medical examination, the examiner noted normal psychiatric system. The Veteran was 71 inches tall and weighed 223 pounds. See December 2014 STR - Medical.

A February 2007 pre-deployment health assessment noted fatigue, malaise, or multisystem complaint. Treatment records show the Veteran denied difficulty sleeping in March 2008. A May 2008 report of medical assessment noted no sleep issues. A May 2008 post-deployment health assessment indicated that the Veteran was not still feeling tired after sleeping. August 2008 and November 2008 post-deployment health assessments noted no sleep problems. A May 2010 pre-deployment health assessment noted fatigue, malaise, or multisystem complaint.

An August 2010 pre-deployment health assessment noted fatigue, malaise
71 inches tall and weighed 223 pounds. See December 2014 STR - Medical.

An August 2010 pre-deployment health assessment noted fatigue, malaise, or multisystem complaint. See April 2017 STR. On an August 2010 TBI questionnaire, the Veteran reported no sleep problems. See December 2014 Medical Treatment Record - Government Facility. An October 2010 pre-deployment health assessment for Afghanistan noted fatigue, malaise, or multisystem complaint.

A June 2011 report of medical assessment noted no sleep issues. See April 2017 STR. A July 2011 post-deployment health assessment for Afghanistan noted no sleep problems. See December 2014 Medical Treatment Record - Government Facility. A November 2011 post-deployment health assessment noted no sleep issues. See April 2017 STR.

A July 2015 OER showed the Veteran was 72 inches tall and weighed 234 pounds. See March 2023 DPRIS Response.

A November 2015 VA examination for his PTSD noted sleep troubles during his first deployment. The VA examiner noted chronic sleep impairment. See November 2015 C&P Exam.

An August 2016 mental health assessment noted no sleep problems. See December 2014 Medical Treatment Record - Government Facility.

Private treatment records from November 2016 show that the Veteran suffered from chronic obesity. In December 2016 the Veteran underwent a sleep study and was diagnosed with severe, positional OSA. His BMI was 34. See July 2019 Buddy/Lay Statement.

A March 2017 VA examination for PTSD showed the Veteran reported he was recently diagnosed with OSA and a CPAP was recommended. However, he chose to use a mandibular device and stated his sleep had improved since he began using it. The VA examiner noted chronic sleep impairment. See March 2017 C&P Exam.

A June 2019 letter from the Veteran's private pulmonologist indicated that a sleep study was performed and the Veteran was diagnosed with severe OSA in December 2016. The pulmonologist indicated that although December 2016 was the time of diagnosis, this condition can be present for tens of years before being discovered, as often symptoms are mild or unnoticed. Because of this, it was very possible, in fact likely, that the Veteran had this condition at the time three years prior when he was still employed.

A medical article regarding the association between sleep apnea and cervical spine disorders was associated with the claims file in March 2021. The article noted that spinal cord injuries weaken the breathing muscles in the diaphragm, severely altering normal breathing processes. Additionally, patients with injuries to or disorders in the seven vertebrae in the cervical spine, which is located directly behind the airway in the neck, are especially susceptible to sleep apnea. While this fact is widely accepted in the medical field, researchers are still striving to define and understand the specific connections between cervical spine disorder pathologies and sleep apnea. See March 2021 Third Party Correspondence.

During the applicable evidentiary window, following the Veteran's Board hearing, the Veteran submitted a private medical opinion dated in August 2024 from physician's assistant W.R.

W.R. reviewed the Veteran's claims file, noting his service from October 1992 through December 2015, as well as service treatment records and lay statements from the Veteran and his wife, which indicated his sleep disorder symptoms began after he returned home from his second deployment to Afghanistan in 2012.

Citing to multiple references, W.R. indicated that medical studies have proven that patients with mental health disorders, such as anxiety disorders, depression, PTSD, and other psychiatric disorders, have almost three times the incidence of OSA versus patients without PTSD regardless of other OSA risk factors. With the high rates of mental health conditions, including PTSD, among the Veteran population, it is widely known that the Veteran population has a higher prevalence for developing OSA.

W.R. also opined that it was at least as likely as not that, but for the Veteran's mental health and orthopedic conditions, he would not have experienced his significant weight gain. Medical documentation from November 2016 records his weight
in 2012.

Finally, W.R. stated that it was more likely than not that, but for the Veteran's weight gain, he would not have developed his OSA symptoms. As a result of the Veteran's gaining weight, his BMI of 33.76 placed him into the severely obese category. Medical research has shown that patients can begin to have a 6-fold increase in the risk of OSA development starting with a 10% weight increase. Since his BMI was above 30, this placed the Veteran well within the risk factor category. As his weight increased, he began to experience upper airway collapse during periods of sleep due to the mechanical effects on his pharyngeal soft tissues, which lead to his OSA diagnosis. See August 2024 Medical Treatment Record - Non-Government Facility.

After resolving reasonable doubt in the Veteran's favor, the Board finds that entitlement to service connection for OSA, to include as secondary to service-connected disabilities, is warranted.

The Veteran was diagnosed with OSA in December 2016, approximately one year after leaving service. And while the Veteran's service treatment records and service personnel records are silent for sleep issues until the November 2015 VA examination for his PTSD, the Veteran reported sleep issues that stemmed from his 2011 Afghanistan deployment.

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The claims file shows that the Veteran was 72 inches tall and weighed 205 pounds in his February 2003 OER, which was shortly before reentering active duty. His calculated BMI was 27.8, which fell in the "overweight" category. Towards the end of his last active duty period, the July 2015 OER showed the Veteran was 72 inches tall and weighed 234 pounds, with a calculated BMI of 31.7, which fell into the "obese" category. His December 2016 sleep study showed a BMI of 34. See https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.

Accordingly, and resolving reasonable doubt in the Veteran's favor, the Board finds that entitlement to service connection for OSA, to include as secondary to his service-connected disabilities with obesity as an intermediate step, is warranted. The claim is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 999 F.3d at 1394.

S. HENEKS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board K. Garey

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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