SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, a retired Master Sergeant of the United States Air Force with service in the Marine Corps (1978-1980) and Air Force (1990-1991, 1990-1990 Reserve, and later active duty periods), appeals the denial of service connection for sleep apnea on a secondary basis. The Veteran was previously granted service connection for PTSD, major depression, generalized anxiety disorder, insomnia, and alcohol use disorder at a 70% rating. The primary issue is whether the sleep apnea is secondary to these service-connected psychiatric conditions. The Veteran submitted lay statements from himself and his wife detailing the onset and worsening of sleep disturbances, nightmares, and alcohol use following his wife's suicide during his service, which he attributes to PTSD. He also submitted a private physician's opinion stating it was at least as likely as not that his sleep apnea was directly attributable to the long-term consequences of his service-connected PTSD and related psychiatric disorders, noting the strong association between PTSD, chronic sleep disruption, and increased risk of obstructive sleep apnea. The Board found this private opinion to be significant and persuasive, as it provided a clear pathophysiological link and was not contradicted by any contrary medical opinion. The Board granted service connection for sleep apnea on a secondary basis.

Rationale

Current diagnosis of sleep apnea established.; Private physician opinion found at least as likely as not that sleep apnea was directly attributable to long-term consequences of service-connected PTSD and related conditions.; No contrary medical opinion of record.

Full Decision Text

Citation Nr: A26040792
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 210909-184105
DATE:         April 30, 2026

ORDER

Entitlement to service connection for sleep apnea, secondary to service-connected psychiatric disorder characterized as posttraumatic stress disorder (PTSD), major depression, generalized anxiety disorder, insomnia and alcohol use disorder, on a causation basis, is granted.

FINDING OF FACT

The Veteran's service-connected disabilities, including his psychiatric disorders, caused his sleep apnea.

CONCLUSION OF LAW

The criteria are met for entitlement to service connection for sleep apnea, on a secondary, causation basis, due to service-connected disabilities including his psychiatric disorders.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran, a retired Master Sergeant of the United States Air Force, served on active duty in the United States Marine Corps from August 1978 to October 1980 and the United States Air Force from November 1990 to June 1991.  The Veteran also had additional service in the United States Air Force Reserve from November 1990 to February 1990, with periods of active service in June 2002, July 2002, and April 2003, as well as periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA).  For his meritorious service, he was awarded the Air Force Reserves Meritorious Service Medal with 1 Oak Leaf Cluster and the Air Force Commendation Medal with 1 Oak Leaf Cluster, as well as other awards and decorations.

In a May 2021 VA 20-0995, Decision Review Request: Supplemental Claim, the Veteran indicated that he was seeking review of the December 2013 rating decision as to the issue of entitlement to service connection for sleep apnea.

In a July 2021 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO), in relevant part, confirmed and continued the prior denial of entitlement to service connection for sleep apnea.

The Veteran timely appealed the July 2021 rating decision to the Board of Veterans' Appeals (Board) in a September 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and requested a hearing with a Veterans Law Judge.  38 C.F.R. §§ 20.202(b)(2); 20.302(a)(2).

In an appeal in which the appellant requested, on the Notice of Disagreement, a Board hearing, the Board's decision is based on a review of the evidence of record at the time of the decision on the issue on appeal, evidence submitted by the Veteran or his representative at the hearing, to include testimony provided at the hearing, and evidence submitted by the Veteran or his representative within 90 days following the hearing.  38 C.F.R. 20.302(a).  However, in June 2025, the Veteran, by and through his representative, notified VA that he withdrew his hearing request, and maintained the 90-day evidentiary window following withdrawal of the hearing request.  38 C.F.R. § 20.704(e).  As such, the Board's decision is based on a review of the evidence of record at the time of the July 2021 rating decision as to the issue of entitlement to service connection for sleep apnea, evidence submitted by the Veteran or his representative within 90 days following the June 2025 request to withdraw his hearing request.

Service Connection

Service connection is warranted where the facts, shown by evidence, establish that a current disability resulted from an injury or disease incurred in active military service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury.  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Service connection is warranted "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(d).

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the
  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury.  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Service connection is warranted "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(d).

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) caused by or (b) aggravated by a service-connected disability.  38 C.F.R. § 3.310(a)-(b).  Secondary causation exists when, but for the service-connected disability, the non-service-connected disability was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain.  Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (citations omitted).  Secondary aggravation exists when the non-service-connected disability not caused by a service-connected disability would be less severe were it not for a service-connected disability.  Id. at 1364.  For example, secondary aggravation may be established where the natural progression of the non-service-connected disability could have been arrested or improved but for the service-connected disability.  Id.

Although obesity is not a disability for VA compensation purposes, 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).  VAOPGCPREC 1-2017; Marcelino v. Shulkin, 29 Vet. App. 155 (2018) (affirming the Board's decision that service connection is not warranted for obesity as it is not in and of itself a disability for VA purposes, but not addressing VAOPGCPREC 1-2017).  In order to establish service connection on this basis, three criteria must be met: (1) the service-connected disability 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) the disability for which service connection is sought would not have occurred but for obesity caused by the service-connected disability.  Id.

Lay statements may be competent to support a claim for service connection by establishing the occurrence of lay-observable events, the presence of disability or symptoms of disability, and the presence of continuous symptoms after separation from service.  See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) ("38 U.S.C. § 1154(a) requires that the VA give 'due consideration' to 'all pertinent medical and lay evidence' in evaluating a claim to disability or death benefits"); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007) ("finder of fact must consider the credibility and weight of the [veteran's] statements, and any other competent lay or medical evidence submitted, to determine whether [the veteran] is entitled to service connection based on continuity of symptomatology"); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) ("Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional."); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (2006) (lay evidence concerning the onset of symptoms and continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence).

All favorable findings towards claimants are binding upon all subsequent adjudicators, unless clear and unmistakable evidence is shown to the contrary to rebut such favorable findings.  38 U.S.C. §§ 5104(b)(4), 5104A; 38 C.F.R. § 20.801(a).

"When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant."  38 U.S.C. § 5107(b).
37 (2006) (lay evidence concerning the onset of symptoms and continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence).

All favorable findings towards claimants are binding upon all subsequent adjudicators, unless clear and unmistakable evidence is shown to the contrary to rebut such favorable findings.  38 U.S.C. §§ 5104(b)(4), 5104A; 38 C.F.R. § 20.801(a).

"When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant."  38 U.S.C. § 5107(b).  Thus, the benefit-of-the-doubt doctrine applies "if the competing evidence is in 'approximate balance,'" and when "the evidence is not in equipoise but nevertheless is in approximate balance."  Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc).  A "low standard of proof" must be employed to "resolve a scientific or medical question in the claimant's favor so long as the evidence for and against that question is in 'approximate balance.'"  Wise v. Shinseki, 26 Vet. App. 517, 531 (2014).  "Congress has not mandated that a medical principle have reached the level of scientific consensus to support a claim for VA benefits."  Id.  Thus, an absolutely "accurate determination of etiology is not a condition precedent to granting service connection; nor is definite etiology or obvious etiology."  See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing 38 U.S.C. § 5107(b)).  However, "the benefit-of-the-doubt rule does not apply" when "the evidence is not in 'approximate balance' or 'nearly equal,'" and "the evidence persuasively favors one side or the other."  Lynch at 781-82.

Entitlement to service connection for sleep apnea

Factual Considerations 

An October 2000 private treatment record indicates that the Veteran was obese and he weighed 210 pounds.  A May 2001 private treatment record indicates that the Veteran weighed 223 pounds.  In a November 2001 private treatment record, a physician noted that the Veteran weighed 232 pounds, which was a 10-pound weight gain since his last office visit.

A March 2006 private treatment record reflects a diagnosis of mild obstructive sleep apnea.

In a July 2012 VA 21-526 Veterans Application for Compensation or Pension, the Veteran indicated that he was seeking entitlement to service connection for sleep apnea, which he indicated began in September 2001 and had been treated at an Air Force Base.

A November 2013 VA examination reflects a diagnosis of tinnitus.  The examiner noted that the Veteran's tinnitus impacted his ability to work.  Specifically, the Veteran reported that he had difficulty falling asleep due to his tinnitus.

In a December 2013 rating decision, the RO, in relevant part, 1) granted entitlement to service connection for tinnitus with a 10 percent rating effective July 27, 2012.  2) Denied entitlement to service connection for sleep apnea.  The RO found that the medical evidence of record failed to show that sleep apnea had been clinically diagnosed.  The evidence did not show an event, disease or injury in service.  The Veteran's service treatment records did not contain complaints, treatment, or diagnosis for sleep apnea.

A September 2020 VA treatment record reflects diagnoses of alcoholic fatty liver and obesity.  The clinician noted that the Veteran was encouraged to avoid alcohol and Tylenol and to lose weight.

In December 2020 and February 2021 statements in support of his claim, the Veteran stated that he served in the United States Marine Corps from August 1978 to October 1980.  During service, he married his childhood girlfriend in June 1970.  He had known her since grade school.  They had a daughter in November 1979.  After the birth of their child, his wife became very ill and was admitted to the intensive care unit because her chemical balanced had been altered.  She committed suicide in July 1980 after the Veteran returned to service from leave.  The Veteran blamed himself for her suicide.  The Veteran found out much later that she had been suffering from post-partum childbirth syndrome.  The Veteran returned home for his wife's funeral.  He reported that he had been having recurring nightmares about his wife.  He reported that he would sometimes fight and punch his current wife in sleep as well as knocking over bedside
 his childhood girlfriend in June 1970.  He had known her since grade school.  They had a daughter in November 1979.  After the birth of their child, his wife became very ill and was admitted to the intensive care unit because her chemical balanced had been altered.  She committed suicide in July 1980 after the Veteran returned to service from leave.  The Veteran blamed himself for her suicide.  The Veteran found out much later that she had been suffering from post-partum childbirth syndrome.  The Veteran returned home for his wife's funeral.  He reported that he had been having recurring nightmares about his wife.  He reported that he would sometimes fight and punch his current wife in sleep as well as knocking over bedside lamps and would wake 4 to 5 times a night.  He stated that he was diagnosed with sleep apnea years ago.  He stated that his nightmares had worsened as he got older.  He also reported that he drank heavily after separation from the Marine Corps.

In January 2021, the Veteran submitted a statement from his sister.  She stated that her current sister-in-law expressed to her that he would often relive the event of his wife's death in his dreams.  His sister also stated that he had become a strong drinker of alcohol, which he believed would at least numb the pain.

The Veteran was afforded a VA examination in April 2021, which reflects a diagnosis of PTSD, recurrent severe major depression, generalized anxiety disorder, insomnia, and unspecified alcohol use disorder.  The examiner noted that the Veteran consumed one liter of whiskey weekly.  The examiner noted that the Veteran had overlapping symptoms from each disorder that preclude identifying which disorder was specific for which set of symptoms without speculation.  For example, his sleep interruption and insomnia were a feature of alcohol abuse, PTSD, depression and anxiety; his anxiety was affected by his PTSD and his PTSD affected his depression.  The Veteran's PTSD appeared to be the initial cause of his subsequent disorders.  The examiner noted that the symptoms of the Veteran's psychiatric disorder included sleep disturbance and chronic sleep impairment.

In an April 2021 rating decision, the RO granted entitlement to service connection for PTSD, major depression, generalized anxiety disorder, insomnia and alcohol use disorder with a 70 percent rating effective January 5, 2021.

In the May 2021 supplemental claim, the Veteran asserted that his sleep apnea was secondary to his service-connected tinnitus.

In May 2021, the Veteran was afforded a VA examination, which reflects a diagnosis of obstructive sleep apnea.  During the examination, the Veteran reported that he would wake up at night all the time with crazy dreams.  He reported that he would wake up not feeling refreshed.  The examiner opined that the Veteran's sleep apnea was less likely than not proximately due to or the result of the Veteran's tinnitus.  The examiner noted that there was no pathophysiologic mechanism for tinnitus to cause sleep apnea.

In July 2021, the Veteran submitted a statement from his current wife.  She stated that she had known the Veteran since he was an adolescent and had been married to him for thirty-nine years.  She stated that she had been with him before, during, and after his military career.  She noticed his medical changes throughout the years during his military career and deployments.  She stated that when he went to sleep, he would still wake up in the morning feeling uneasy as if he had no rest at all.  He would toss and turn throughout the night.  He would be up at different hours of the night, because he had a hard time staying asleep.  Due to the fact he did not get sufficient sleep, it would make him irritable.  He had extremely loud snoring no matter what time of the day, which caused her to be unable to sleep.  He would choke a lot in his sleep and would wake up grabbing at his chest.  It appeared to her that he would stop breathing.  A lot of times she would have to wake him when that happened, because he would be in a deep sleep.  In addition, he would regurgitate in his sleep while he was choking.  He would also complain of chest pains and headaches.  He would sleep a lot during the daytime with loud snoring.  She stated that the Veteran did not have these symptoms prior to military service and it had worsened over the years.

In the July 2021 rating decision, the RO confirmed and continued the prior denial of entitlement to service connection for sleep apnea.  The RO favorably found that the Veteran was service connected for tinnitus.  The Veteran had a current diagnosis of sleep apnea.  However, service connection for sleep apnea was not established because the records failed to show that the condition was secondary to tinnitus.

In June 2025, the
 would regurgitate in his sleep while he was choking.  He would also complain of chest pains and headaches.  He would sleep a lot during the daytime with loud snoring.  She stated that the Veteran did not have these symptoms prior to military service and it had worsened over the years.

In the July 2021 rating decision, the RO confirmed and continued the prior denial of entitlement to service connection for sleep apnea.  The RO favorably found that the Veteran was service connected for tinnitus.  The Veteran had a current diagnosis of sleep apnea.  However, service connection for sleep apnea was not established because the records failed to show that the condition was secondary to tinnitus.

In June 2025, the Veteran's representative asserted that a review of the relevant medical literature provided support for a causal association between the Veteran's service-connected tinnitus and sleep apnea.

In June 2025, the representative submitted an article titled "Association Between Sleep Apnea and Tinnitus: A Meta-Analysis" from Ear, Nose and Throat Journal dated January 2024.  The article indicated that severe sleep apnea may be related to tinnitus in adults.  Overall, the meta-analysis results suggested that sleep apnea may be associated with a higher prevalence of tinnitus in adults, especially for patients with severe sleep apnea and for patients from Western countries.  The results were mainly contributed by studies investigating the association between obstructive sleep apnea and tinnitus.

In July 2025, the representative submitted an opinion from a private physician who opined that it was at least as likely as not that the Veteran's current diagnosis of obstructive sleep apnea was directly attributable to the long-term physiological, psychological, and metabolic consequences of his service-connected PTSD and related conditions.  The physician noted that the Veteran's long-standing diagnosis of obstructive sleep apnea was at least as likely as not secondary to his service-connected PTSD, with contributing effects from major depressive disorder, chronic insomnia, and alcohol use disorder.  As established in the clinical literature, PTSD was strongly associated with chronic sleep disruption, hyperarousal, and hormonal dysregulation, all of which impair normal respiratory function during sleep and significantly increase the risk of obstructive sleep apnea.  The Veteran's psychiatric symptoms particularly persistent insomnia, nightmares, and emotional dysregulation set in motion a progressive cycle of sleep fragmentation, alcohol use as a form of self-medication, and gradual metabolic deterioration.  Medical records documented that the Veteran maintained a healthy BMI of 23.6 during his early military service in 1980 but following discharge and the chronic progression of PTSD-related symptoms, his BMI increased to 26.4 (overweight) by 1991 and reached 31.5 (Class I obesity) by 2004.  This trajectory of weight gain mirrored the onset and worsening of hallmark obstructive sleep apnea symptoms such as daytime fatigue, loud snoring, and waking up gasping for air, well before his formal diagnosis.  The development of obstructive sleep apnea was further aggravated by his prolonged alcohol use, which was both a consequence of untreated PTSD and a clinical risk factor for worsening apneic episodes through upper airway muscle relaxation, reduced arousal response, and increased nasal resistance.

Analysis

For reasons set forth below, the likelihood is approximately evenly balanced, if not higher, that the Veteran's sleep apnea disability was caused by his service-connected disabilities, including his psychiatric disorders.

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?

A current diagnosis of sleep apnea has been established.

Significant probative weight is given to the July 2025 private physician's opinion that it was at least as likely as not that the Veteran's current diagnosis of obstructive sleep apnea was directly attributable to the long-term physiological, psychological, and metabolic consequences of his service-connected PTSD and related conditions.  The physician explained the reasons for the conclusions based on an accurate characterization of the evidence of record.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning).  There is no contrary medical opinion of record.

 

 

RAY BARTO SLABBEKORN, JR.

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	G. Johnson, 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.