SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, an Army veteran who served from December 2003 to March 2005, including service in Kuwait, appeals the denial of service connection for obstructive sleep apnea (OSA). The Veteran claims OSA is secondarily caused by his service-connected other specified insomnia disorder, leading to weight gain and obesity. He also contended it was secondary to his service-connected asthma and tinnitus. The Veteran's service treatment records did not document any sleep-related complaints. The Board reviewed multiple VA examinations and a private medical opinion. The VA examiners opined that OSA was less likely than not caused by toxic exposures or proximately due to his service-connected asthma, citing a lack of medical literature linking asthma to OSA. They also found OSA less likely than not related to his service-connected insomnia disorder, stating they are distinct conditions. However, the Board found these VA opinions inadequate as they did not fully address the Veteran's theory of weight gain from his psychiatric disorder causing OSA, nor did they consider all the evidence. The Board gave significant weight to a private medical opinion from a board-certified physician, which positively linked OSA to weight gain caused by the service-connected insomnia disorder, referencing studies on depression and obesity. The Board found this private opinion more probative and, applying the benefit of the doubt, granted service connection for OSA on a secondary basis due to weight gain caused by the service-connected insomnia disorder. The Board noted that while obesity itself is not a ratable condition, it can serve as an intermediate step in secondary service connection claims.

Rationale

Private medical opinion found OSA secondary to weight gain from service-connected insomnia disorder.; VA opinions failed to adequately address the Veteran's theory of weight gain from psychiatric disorder causing OSA.; Benefit of the doubt doctrine applied.

Full Decision Text

Citation Nr: A26040535
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 250818-575452
DATE: April 30, 2026

ORDER

Service connection for obstructive sleep apnea is granted.

FINDING OF FACT

The Veteran's sleep apnea is caused by his service-connected other specified insomnia disorder disability.

CONCLUSION OF LAW

The criteria for service connection for obstructive 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 FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from December 2003 to March 2005, including service in Kuwait.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2025 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) under the modernized appeals system known as the Appeals Modernization Act.

By way of background, the Veteran filed an initial claim for service connection for sleep apnea in February 2024.  See February 2024 VA Form 21-526EZ.  The claim was denied by the AOJ in a June 2024 rating decision.

The Veteran filed VA Form 20-0996, Request for Higher-Level Review (HLR), in June 2024, seeking review of the June 2024 rating decision.  In a September 2024 rating decision, the AOJ confirmed and continued the denial of service connection for sleep apnea.

In December 2024, the Veteran filed VA Form 20-0995, Supplemental Claim, seeking service connection for sleep apnea.

In March 2025, the AOJ found that new and relevant evidence had been received for the claim of service connection and the claim was reconsidered; however, the AOJ confirmed and continued the denial of service connection for sleep apnea.

The Veteran filed another VA Form 20-0996, HLR, in April 2025, seeking review of the March 2025 rating decision.

In May 2025, the AOJ issued the HLR rating decision on appeal, denying entitlement to service connection for sleep apnea.  The HLR decision considered the evidence of record at the time of the prior March 2025 rating decision.

In the August 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 March 2025 agency of original jurisdiction (AOJ) decision, which was subsequently subject to higher-level review, 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, which was subsequently subject to higher-level review, 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.

Service connection for obstructive sleep apnea

The Veteran seeks service connection for obstructive sleep apnea (OSA), which he asserts is secondarily caused by his service-connected other specified insomnia disorder.  See December 2024 Supplemental Claim; see also December 2024 Statement in Support of Claim.  The Veteran asserted that he weighed approximately 190 pounds upon separation from service, and now weighed approximately 207 pounds.  See June 2025 Private Medical Opinion.

Alternatively, the Veteran also contends that his OSA is secondarily caused by his service-connected asthma and tinnitus disabilities.  See February 2024 VA Form 21-526EZ; see also February 2024 Lay Witness Statement.

The Veteran's service treatment records (STRs) do not contain any complaints, treatment, or diagnoses for a
ive sleep apnea (OSA), which he asserts is secondarily caused by his service-connected other specified insomnia disorder.  See December 2024 Supplemental Claim; see also December 2024 Statement in Support of Claim.  The Veteran asserted that he weighed approximately 190 pounds upon separation from service, and now weighed approximately 207 pounds.  See June 2025 Private Medical Opinion.

Alternatively, the Veteran also contends that his OSA is secondarily caused by his service-connected asthma and tinnitus disabilities.  See February 2024 VA Form 21-526EZ; see also February 2024 Lay Witness Statement.

The Veteran's service treatment records (STRs) do not contain any complaints, treatment, or diagnoses for a sleep-related condition.

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service.  See 38 U.S.C. § 1110; 38 C.F.R. § 3.303.  A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Service connection may be established for disability that is caused or aggravated by a service-connected disability.  38 C.F.R. § 3.310.  El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Allen v. Brown, 7 Vet. App. 439 (1995).

Although obesity is not a condition for which service connection may be granted, obesity may qualify as an "intermediate step" between a service-connected disability and another current disability.  See VAOPGCPREC 1-2017; see also Garner v. Tran, 33 Vet. App. 241 (2021); Walsh v. Wilkie, 32 Vet. App. 300 (2020).  In a secondary service connection claim, a theory of obesity as an intermediate step is raised when there is some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition.  Garner v. Tran, 33 Vet. App. 241 (2021).

In a December 2024 Statement in Support of Claim, the Veteran stated that his chronic insomnia has been a significant contributor to his sleep disturbances, and the fragmented sleep created a cycle of exhaustion and worsening OSA symptoms, leaving the Veteran fatigued and unable to function properly during the day.  He added that his insomnia symptoms make it difficult to get proper rest and sleep, and the interrupted sleep includes symptoms of excessive snoring and trouble breathing, which has resulted in exhaustion and a strain on his personal activities and relationships.  The Veteran elaborated that his lack of sleep exacerbates his OSA symptoms, creating problems such as poor concentration, lack of energy, and an overall diminished quality of life.

The Veteran was afforded a VA sleep apnea examination in April 2024, which confirmed a diagnosis of OSA with required use of a CPAP machine.  The examination report documented Veteran's previous complaints of worsening symptoms of snoring, witness apnea, and daytime sleepiness.  The Veteran underwent a sleep study in February 2015, which found a diagnosis of mild obstructive sleep apnea.  The Veteran did not require continuous medication or use of a breathing assistance device for his OSA disorder.

The April 2024 VA examiner opined that the Veteran's OSA was less likely than not caused by the Veteran's indicated toxic exposure risk activities (TERAs), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERAs of the Veteran.  The VA examiner also opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service-connected asthma condition, citing the lack of medical literature establishing a nexus between the presence of asthma as a link for the development of OSA.

The Veteran submitted findings from medical treatises along with his December 2024 VA Form 20-0995, Supplemental Claim, that established a link between the development of OSA and mental health disorders.  The findings included a study that following a 10-year trend of sleep apnea among male veterans, psychological distress, and unmet mental health showing veterans with "mild to moderate past-year psychological distress had 61%
As of the Veteran.  The VA examiner also opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service-connected asthma condition, citing the lack of medical literature establishing a nexus between the presence of asthma as a link for the development of OSA.

The Veteran submitted findings from medical treatises along with his December 2024 VA Form 20-0995, Supplemental Claim, that established a link between the development of OSA and mental health disorders.  The findings included a study that following a 10-year trend of sleep apnea among male veterans, psychological distress, and unmet mental health showing veterans with "mild to moderate past-year psychological distress had 61% higher odds of sleep apnea in the past year and those with serious psychological distress had 138% higher odds."  See December 2024 Correspondence.

The Veteran was afforded another VA sleep apnea examination in January 2025, which reaffirmed his OSA diagnosis.  The Veteran reported that the onset of his OSA was in 2015, when it was diagnosed incidentally through PCP during work up for atrial fibrillation; the Veteran reported that he tried the CPAP machine in 2015 but stopped using it after it was unsuccessful in alleviating his symptoms.  He noted that he experiences snoring and persistent daytime hypersomnolence, and wakes during the night three times weekly with mild headaches; he also reported decreased focus in both work and social situations.  

The January 2025 VA examiner opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service-connected other specified insomnia disorder, noting that the insomnia disorder and OSA may co-occur but are distinct conditions with different pathophysiologies.  Therefore, the VA examiner concluded that the Veteran's OSA is not medically related to the other specified insomnia disorder, and a nexus cannot be established to demonstrate a causal relationship between the two conditions.

Here, the Veteran has a current diagnosis of OSA.  The critical question in this case is the etiology of the diagnosed OSA.  The Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record.  In this case, the Veteran's primary theory of entitlement is that due to his service-connected other specified insomnia disorder, he experienced weight gain and obesity, that caused his obstructive sleep apnea.

In August 2025, the Veteran submitted a June 2025 private medical opinion, written by a board-certified physician, in support of his service connection claim.  The physician opined positively and held it was at least as likely as not that the Veteran's OSA is secondary to, related to, and/or aggravated by his service-connected unspecified insomnia disorder and weight/gain obesity.  This examiner noted that the Veteran's service-connected psychiatric disorder has made his daily activities progressively strenuous and left the Veteran in a mentally debilitating and lonely circumstance, due to which his sedentary lifestyle has led to an increased daily caloric intake which in turns has led to weight gain; the physician stated that the OSA is directly correlated to his consequential weight gain.  Subsequent to the examiner's rationale in associating obesity as a major risk factor for developing OSA, the examiner noted that depression is a risk factor for weight gain/obesity, referencing a study that noted "adults with depression were more likely to be obese than adults without depression" and "43% of adults with depression were obese as compare with 33% of adults without depression."  The physician concluded the opinion with opining that the current OSA is aggravated by, related to, and secondary to weight gain caused by Veteran's unspecified insomnia disorder; the physician added that, but for the weight gain and obesity, Veteran's OSA would not have occurred.

While the Board acknowledges the negative VA medical opinions from April 2024 and January 2025, the Board notes that these medical opinions failed to adequately address the Veteran's contention that his weight gain/obesity, stemming from his service-connected psychiatric disorder, was a cause for his development of OSA.  The VA examiners' opinions did not consider the Veteran's competent lay testimony and the entire medical evidence of record; therefore, these opinions are not afforded great probative weight.  As such, in its role as a finder of fact, the Board finds that the competent and credible evidence shows that the Veteran's OSA is caused by his weight gain due to the manifestations and symptoms of the Veteran's service-connected psychiatric disability.  See Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).

In light of the foregoing, the Board finds that service connection for obstructive sleep apnea is warranted on a secondary basis.  See 38
 a cause for his development of OSA.  The VA examiners' opinions did not consider the Veteran's competent lay testimony and the entire medical evidence of record; therefore, these opinions are not afforded great probative weight.  As such, in its role as a finder of fact, the Board finds that the competent and credible evidence shows that the Veteran's OSA is caused by his weight gain due to the manifestations and symptoms of the Veteran's service-connected psychiatric disability.  See Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).

In light of the foregoing, the Board finds that service connection for obstructive sleep apnea is warranted on a secondary basis.  See 38 C.F.R. § 3.310(a).  The benefit of the doubt doctrine applies.  38 U.S.C. § 5107(b), Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).  As such, service connection for obstructive sleep apnea as caused by the Veteran's service-connected unspecified insomnia disorder disability is warranted.

 

 

S. Sorathia 

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Ahmed, Zarar

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.