SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, an Army Veteran who served from December 1987 to July 1991, appeals the denial of service connection for obstructive sleep apnea and a heart disability. The Board reviewed the evidence, including a VA examination from October 2020 and a private medical opinion from the Veteran's treating provider, Dr. M.C., dated May 2021. The VA examiner opined that the Veteran's obstructive sleep apnea was less likely than not related to his service-connected PTSD, citing a lack of causative link despite studies showing an association. Conversely, Dr. M.C. found it at least as likely as not that the sleep apnea was caused by PTSD, referencing medical literature and the Veteran's long-standing treatment history. The Board found Dr. M.C.'s opinion more probative due to its specificity to the Veteran's history and the treating relationship. For the heart disability, the Veteran claimed it was due to PTSD and environmental exposures, including nerve agents from Iraq. A December 2010 VA exam noted risk factors but did not link them to service or fully explain the etiology. An October 2020 VA exam found the heart disability not related to PTSD but lacked specific rationale. Dr. M.C. opined the Veteran's military service in Iraq significantly contributed to his coronary artery disease, noting the Veteran lacked typical risk factors. The Board found Dr. M.C.'s opinion more persuasive due to its specificity and the treating relationship, and resolved doubt in the Veteran's favor. Service connection for obstructive sleep apnea and the heart disability was granted.

Rationale

Private medical opinion from treating provider found more probative; Opinion linked sleep apnea to PTSD based on medical literature and Veteran's history; Resolved doubt in Veteran's favor

Full Decision Text

Citation Nr: A26040643
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 210803-176524
DATE: April 30, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea is granted.

Entitlement to service connection for a heart disability, to include coronary artery disease, is granted.

FINDINGS OF FACT

1. Resolving any reasonable doubt in the Veteran's favor, his current obstructive sleep apnea is proximately due to or the result of his service-connected posttraumatic stress disorder (PTSD).

2. Resolving any reasonable doubt in the Veteran's favor, his current heart disability, to include coronary artery disease, is proximately due to or the result of his military service.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for obstructive sleep apnea as secondary to service-connected disabilities have been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for entitlement to service connection for a heart disability, to include coronary artery disease, have been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from December 1987 through July 1991.

This case is before the Board of Veterans' Appeals (Board) on an appeal from a July 2021 rating decision issued by the Agency of Original Jurisdiction (AOJ).

In August 2021, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement). The Veteran selected the hearing docket. A Board hearing was held on September 10, 2024.

Therefore, the Board may only consider the evidence of record at the time of the July 2021 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his 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.

Law and Analysis

As a preliminary matter, the Board notes that the Veteran initially filed a claim in 2010 for service connection for heart attack due to undiagnosed illness, and subsequently in 2020 filed a claim for service connection for heart disease, and in 2021 filed a claim for service connection for a heart condition. In Clemons v. Shinseki, the United States Court of Appeals for Veterans Claims (Court), noted that the Board should consider alternate current disorders within the scope of the filed claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has preliminarily reviewed the case at hand and finds that the holding in Clemons is applicable here. In light of Clemons, the Board has framed the issue as entitlement to service connection for a heart disability, to include coronary artery disease, as reflected on the title page.

The Board also notes, as an initial matter, that the Veteran's representative raised issues with the pre-decisional duty to assist, including that following a finding that new and relevant evidence had been obtained in connection with the Veteran's claims, no new examination had been provided in connection with the Veteran's heart disability claim, and that no new medical opinions had been obtained in connection with either claim. See September 2024 Hearing Transcript. Because the Board is granting the Veteran's claims in this matter based upon a private medical opinion submitted by the Veteran, the Board finds that a remand to address any pre-decisional duty to assist errors which may have occurred is unnecessary, and will not be addressed below.

Service connection may be established for
 page.

The Board also notes, as an initial matter, that the Veteran's representative raised issues with the pre-decisional duty to assist, including that following a finding that new and relevant evidence had been obtained in connection with the Veteran's claims, no new examination had been provided in connection with the Veteran's heart disability claim, and that no new medical opinions had been obtained in connection with either claim. See September 2024 Hearing Transcript. Because the Board is granting the Veteran's claims in this matter based upon a private medical opinion submitted by the Veteran, the Board finds that a remand to address any pre-decisional duty to assist errors which may have occurred is unnecessary, and will not be addressed below.

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, air, or space service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also 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.

Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.310(a); Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding that secondary service connection is warranted under the causation standard of 38 U.S.C. § 1110 where a nonservice-connected disability would have been less severe but for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the nonservice-connected disability). The Federal Circuit has held that 38 C.F.R. § 3.310(b) is inconsistent with 38 U.S.C. § 1110.

Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other).

Obstructive Sleep Apnea

In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to service connection for obstructive sleep apnea.

The Veteran contends that his obstructive sleep apnea is the result of his service-connected posttraumatic stress disorder (PTSD). See October 2020 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. The Veteran previously contended that his obstructive sleep apnea is the result of exposure to environmental toxins and chemical warfare agents. See September 2017 VA Form 21-4138, Statement in Support of Claim.

The Veteran was provided with a VA examination regarding his obstructive sleep apnea in October 2020. The VA examiner noted that the Veteran was diagnosed with mild obstructive sleep apnea in October 2016. The VA examiner discussed that while some studies have shown an increased rate of obstructive sleep apnea in veterans with PTSD, there is no causative link between the two of them. The VA examiner explained that associations, suggestions, and elevated risks do not rise to the level of causation that is actually needed to link a medical condition to a specific exposure. The VA examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was proximately due to his service-connected PTSD with major depressive disorder.

In May 2021, the Veteran received a private medical opinion from his treating provider, Dr. M.C., MD, FACC (initials used to protect privacy). Dr. M.C. opined that it was at least as likely as not that the Veteran's obstructive sleep apnea was caused by his service-connected PTSD. In reaching this conclusion, Dr. M.C. discussed that a 2019 article in the Journal of Clinical Sleep Medicine found that there is a close association between obstructive sleep apnea and posttraumatic sleep disorder, which Dr. M.C. noted that the Veteran suffers from. Dr. M.C.'s opinion was based on his knowledge
 proximately due to his service-connected PTSD with major depressive disorder.

In May 2021, the Veteran received a private medical opinion from his treating provider, Dr. M.C., MD, FACC (initials used to protect privacy). Dr. M.C. opined that it was at least as likely as not that the Veteran's obstructive sleep apnea was caused by his service-connected PTSD. In reaching this conclusion, Dr. M.C. discussed that a 2019 article in the Journal of Clinical Sleep Medicine found that there is a close association between obstructive sleep apnea and posttraumatic sleep disorder, which Dr. M.C. noted that the Veteran suffers from. Dr. M.C.'s opinion was based on his knowledge of the Veteran's medical history and his experiences and exposures while in military service. Dr. M.C. has been the Veteran's treating provider for over 15 years. See September 2024 Hearing Transcript.

The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for a medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008).

In the present case, there are two competing opinions: one from the 2020 VA examiner, and the other provided by the Veteran's treating provider. Both of the opinions have been provided by medical professionals who possess the necessary education, training, and expertise to provide the requested opinions. While the VA examiner indicated that the Veteran's VA e-folder had been reviewed, it is likely that the Veteran's provider has a deeper understanding of the Veteran's record and history, since he has been the Veteran's treating provider for over 15 years.

The October 2020 VA examiner's opinion discusses the medical literature and notes that studies have shown an increased rate of obstructive sleep apnea in veterans with PTSD. However, the VA examiner's conclusion that there was no causative link between the Veteran's obstructive sleep apnea and his service-connected PTSD was not supported in the opinion's rationale by citing to any clinical evidence in the Veteran's record, specific medical literature, specific medical studies, or specific principles of medical science. The VA examiner simply noted that associations, suggestions, and elevated risks do not rise to the level of causation. The VA examiner's rationale also does not discuss the Veteran specifically or provide an opinion regarding the etiology of the Veteran's obstructive sleep apnea, other than concluding that it was less likely than not that it was caused by his service-connected PTSD.

On the other hand, the May 2021 medical opinion provided by the Veteran's treating provider, Dr. M.C., both discusses specific medical literature and relates it to the Veteran's specific medical history. Because Dr. M.C.'s medical opinion is specific to the Veteran and is likely based on a greater understanding of the Veteran's specific history, the Board places more probative weight on Dr. M.C.'s medical opinion than it does on the October 2020 VA examiner's opinion.

Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for obstructive sleep apnea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Heart Disability

In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to service connection for a heart disability, to include coronary artery disease.

The Veteran contends that his heart disability was caused by his service-connected PTSD. See October 2020 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. The Veteran also contends that his heart disability was caused by his exposure to environmental toxins and chemical warfare agents. See September 2017 VA Form 21-4138, Statement in Support of Claim. The Veteran was exposed to the nerve agents sarin and cyclosarin when rockets were destroyed at Khamisiyah, Iraq, on March 10, 1991. See July 1997 Letter from Office of the Secretary of Defense.

The Veteran was first provided with a VA examination regarding his heart disability in December 2010. The VA
 artery disease.

The Veteran contends that his heart disability was caused by his service-connected PTSD. See October 2020 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. The Veteran also contends that his heart disability was caused by his exposure to environmental toxins and chemical warfare agents. See September 2017 VA Form 21-4138, Statement in Support of Claim. The Veteran was exposed to the nerve agents sarin and cyclosarin when rockets were destroyed at Khamisiyah, Iraq, on March 10, 1991. See July 1997 Letter from Office of the Secretary of Defense.

The Veteran was first provided with a VA examination regarding his heart disability in December 2010. The VA examiner discussed that the underlying pathogenesis for coronary artery disease is the formation of arteriosclerotic plaques. The VA examiner noted that the Veteran has personal risk factors for coronary artery disease including male gender, positive family history, and hyperlipidemia. The VA examiner concluded that there was no medical evidence supporting exposure to environmental hazards during Gulf War service as a cause or risk factor for the development of coronary artery disease.

While the December 2010 VA examiner ruled out environmental hazards as a cause of the Veteran's heart disability, the VA examiner did not address whether the Veteran's specific exposure to the nerve agents sarin and cyclosarin could have caused the Veteran's heart disability. Additionally, while the VA examiner noted that the Veteran's hyperlipidemia was a risk factor for coronary artery disease, the VA examiner did not provide a complete etiology of the Veteran's heart disability, nor did the VA examiner indicate whether the Veteran's hyperlipidemia was, in fact, the cause of the Veteran's heart disability.

The Veteran was next provided with a VA examination regarding his heart disability in October 2020. The October 2020 VA examiner noted that the medical literature does not support the claim that heart disease is due to PTSD with major depressive disorders, and that it is caused by genetic and disease processes. However, the October 2020 VA examiner did not cite to any specific medical literature or studies to support those statements. The VA examiner concluded that it was less likely than not that the Veteran's heart disability was proximately due to his service-connected PTSD.

In reaching the conclusion that it was less likely than not that the Veteran's heart disability was proximately due to his service-connected PTSD, the October 2020 VA examiner did not specifically discuss the Veteran. The October 2020 VA examiner did not refer to any diagnostic studies or to any specific aspects of the Veteran's medical or military history. The October 2020 VA examiner also did not provide any etiology for the Veteran's heart disability, other than concluding that it was not caused by PTSD.

In May 2021, the Veteran received a private medical opinion from his treating provider, Dr. M.C., regarding his heart disability. Dr. M.C., who is a Fellow of the American College of Cardiology (FACC), opined that the Veteran's military service in Iraq played a significant factor in his development of coronary artery disease and myocardial infarction. Dr. M.C. noted that the Veteran does not have a high-risk profile for coronary artery disease, given that the Veteran has never smoked, that coronary artery disease does not run in the Veteran's family (first-degree relatives), and that he does not have diabetes, hypertension, or an elevated cholesterol.

The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for a medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008).

In the present case, there are three competing opinions: one from the December 2010 VA examination, one from the October 2020 VA examination, and one provided by the Veteran's treating provider. Each of the opinions has been provided by medical professionals who possess the necessary education, training, and expertise to provide the requested opinions. While the VA examiners indicated that they reviewed the Veteran's VA medical records, it is likely that the Veteran's provider has a deeper understanding of the Veteran's record and history,
 the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008).

In the present case, there are three competing opinions: one from the December 2010 VA examination, one from the October 2020 VA examination, and one provided by the Veteran's treating provider. Each of the opinions has been provided by medical professionals who possess the necessary education, training, and expertise to provide the requested opinions. While the VA examiners indicated that they reviewed the Veteran's VA medical records, it is likely that the Veteran's provider has a deeper understanding of the Veteran's record and history, since he has been the Veteran's treating provider for over 15 years.

The December 2010 VA examiner's discussion of the Veteran's risk factors for coronary artery disease are contradictory to that provided by Dr. M.C. The December 2010 VA examiner noted that the Veteran's risk factors included a positive family history. Dr. M.C. noted that coronary artery disease does not run in the Veteran's family (first-degree relatives). The December 2010 VA examiner noted that the Veteran's risk factors also included hyperlipidemia. While he was in service, the Veteran did have a blood test in connection with obtaining a life insurance quote, which showed that his cholesterol was high. See September 2024 Hearing Transcript. However, Dr. M.C. notes that the Veteran does not have an elevated cholesterol. Because Dr. M.C. has been the Veteran's treating provider for over 15 years, the Board finds that Dr. M.C.'s accounting of the Veteran's risk factors for coronary artery disease is likely more accurate than the December 2010 VA examiner's. Accordingly, the Board affords more probative weight to the Veteran's treating provider's opinion than it does to the opinion of the December 2010 VA examiner.

The October 2020 VA examiner's opinion does not specifically discuss the Veteran. The October 2020 VA examiner did not refer to any diagnostic studies or to any specific aspects of the Veteran's medical or military history. The October 2020 VA examiner also did not provide any etiology for the Veteran's heart disability, other than concluding that it was not caused by PTSD. On the other hand, Dr. M.C.'s opinion specifically discusses the Veteran's history and his lack of significant risk factors for coronary artery disease in reaching the conclusion that the Veteran's military service in Iraq played a significant factor in his development of his heart disability. Because Dr. M.C.'s medical opinion is specific to the Veteran and includes a discussion of his specific medical history, and because the October 2020 VA examiner's opinion is not specific to the Veteran and does not include a discussion of him specifically, the Board affords more probative weight to the Veteran's treating provider's opinion than it does to the opinion of the October 2020 VA examiner.

Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a heart disability, to include coronary artery disease, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

 

 

JENNIFER HWA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Schoettmer, Matthew S.

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.