SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, a Veteran who served from January 2001 to January 2005, appeals the denial of service connection for obstructive sleep apnea (OSA). The Veteran claims OSA is secondary to his service-connected left knee degenerative arthritis and left ankle sprain. The Board acknowledges the Veteran's current OSA diagnosis and the established service connection for his knee and ankle conditions. The central issue is whether the OSA is caused or aggravated by these service-connected musculoskeletal conditions, with obesity acting as an intermediate step. The Board found the evidence in relative equipoise, particularly highlighting a private medical opinion from October 2024. This opinion linked the Veteran's weight gain, attributed to inactivity from his knee and ankle conditions, to the development of OSA. The private clinician concluded it was at least as likely as not that the weight gain was related to the service-connected conditions and that OSA was secondary to this weight gain. The Board noted the VA opinion was deficient. Resolving reasonable doubt in the Veteran's favor due to the equipoise and the deficient VA opinion, the Board granted service connection for sleep apnea as secondary to the service-connected knee and ankle conditions.

Rationale

Private medical opinion linked weight gain to service-connected knee/ankle conditions; Weight gain identified as intermediate step to OSA; Evidence in relative equipoise, doubt resolved in Veteran's favor

Full Decision Text

Citation Nr: A26040512
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 260102-619588
DATE: April 30, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea is granted as secondary to service-connected degenerative arthritis, left knee, and left ankle sprain.

FINDING OF FACT

Resolving reasonable doubt in the Veteran's favor, the Board finds that his claimed sleep apnea condition is related to his service-connected left knee and left ankle conditions. 

CONCLUSION OF LAW

The criteria for entitlement to service connection for a sleep apnea condition as due to service-connected left knee and left ankle conditions have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from January 2001 to January 2005. In January of 2026, the Veteran filed a notice of disagreement (NOD) in which he requested the direct review lane in response to an April 2025 supplemental claim rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Under direct review, no development may be undertaken; the Board of Veterans' Appeals considers the same record as the RO in rendering a decision. 

Entitlement to service connection for obstructive sleep apnea is granted as secondary to service-connected degenerative arthritis, left knee, and left ankle sprain.

The Veteran alleges that he has a sleep apnea condition that is related to his military service. Most relevant in this case, secondary service connection may be granted for a disease or injury which resulted from a service-connected disability or was aggravated thereby. 38 C.F.R. § 3.310. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Further, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will also be service connected.

Here, it is uncontroverted that the Veteran has a current sleep apnea disability and the Board also initially acknowledges that it is not in contention that the Veteran has respectively been afforded service connection for both a left knee and left ankle condition. See e.g. April 2025 Rating Decision. Thus, the most relevant question before the Board at this juncture is whether the Veteran's claimed sleep apnea was caused or aggravated by his service-connected left knee and/or left ankle condition.

In regard to a nexus, multiple probative medical nexus opinions are of record, all of which were provided by medical professionals who are presumed to have the training and expertise to opine on sleep apnea conditions. For the sake of brevity, the Board will only highlight the details of the evidence most relevant to this grant.

Most influentially, the Veteran submitted a privately authored positive medical opinion in October of 2024. In addition to extensively outlining medical authorities that address the role obesity plays in regard to the secondary causation of sleep apnea, the clinician concluded that in the case of the Veteran, "it is at least as likely as not (a 50%/50% probability) that the veteran's weight gain is due to and/or related to his service-connected Left Ankle Sprain and Left Knee Degenerative Arthritis; it is at least as likely as not (a 50%/50% probability) that the veteran's Obstructive Sleep Apnea (OSA) condition with CPAP is secondary to, related to, and/or aggravated by the weight gain from the service-connected Left Ankle Sprain and Left Knee Degenerative Arthritis; and it is at least as likely as not (a 50%/50% probability) that without the veteran's weight gain his Obstructive Sleep Apnea (OSA) condition with CPAP would not have occurred."

As attested to by the private clinician, the Board notes that obesity may in fact serve 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). See VAOPGCPREC 1-2017. Further, it was provided among other rationale in that opinion that the Veteran had, "gained 371bs of weight due to inactivity and his service-connected Left Ankle Sprain and Left Knee Degenerative Arthritis. He has taken Aleve (Naproxen/Naprosyn) to treat his service connected musculos
OSA) condition with CPAP would not have occurred."

As attested to by the private clinician, the Board notes that obesity may in fact serve 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). See VAOPGCPREC 1-2017. Further, it was provided among other rationale in that opinion that the Veteran had, "gained 371bs of weight due to inactivity and his service-connected Left Ankle Sprain and Left Knee Degenerative Arthritis. He has taken Aleve (Naproxen/Naprosyn) to treat his service connected musculoskeletal conditions. Obesity/Weight gain is the number one risk factor of developing Obstructive Sleep Apnea and studies further show a relationship between mental health conditions, chronic pain, and chronic sleep impairment. Additionally, he has difficulty sleeping due to pain, difficulty initiating sleep, difficulty maintaining sleep, and being unable to steep on his side. He subsequently developed: trouble sleeping with frequent awakenings, daytime fatigue, snoring, difficulty completing tasks, poor concentration, and pauses in respirations while sleeping. This veteran has been prescribed a CPAP machine."

Thus, while the Board has considered the VA opinion authored in October of 2024, following a review of the evidence of record, the Board finds that the evidence is at least in relative equipoise regarding whether the Veteran's sleep apnea was caused by his service-connected musculoskeletal conditions, and that his obesity acted as an intermediate step between these conditions. In so opining, it is acknowledged that the Veteran has not always contended that entitlement to service connection is warranted on a secondary basis. See e.g. December 2015 VA Form 21-526EZ. 

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Most importantly, because each of the opinions of record constitutes competent, credible medical evidence of record, any lingering doubt is resolved in the Veteran's favor, especially as the relevant VA opinion is deficient and, standing alone, would have provided an insufficient basis upon which to decide this claim. On that basis alone, the Veteran's claim for service connection for sleep apnea is granted. 38 U.S.C. § 5107 (b); see also Lynch v. McDonough, 21 F.4 776 (Fed. Cir. 2021).

 

MICHAEL MARTIN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	K. Smith, 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.