SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran, who served from January 1991 to January 1994 and again from January 1997 to January 2000, appeals the denial of service connection for obstructive sleep apnea on a secondary basis to his service-connected PTSD. The Board reviewed the evidence, including two VA examinations and a private medical opinion. The initial VA examination in July 2023 was given minimal weight as it failed to adequately address the nexus between PTSD, obesity, and sleep apnea. A subsequent VA examination in December 2023 also provided an unfavorable opinion, stating a lack of substantiating evidence for a link to service. However, a private medical doctor in July 2025 provided a favorable opinion, linking the veteran's obstructive sleep apnea to PTSD through the intermediate step of obesity and disruption of REM sleep. The private doctor's opinion was found to be probative and well-reasoned, citing supporting studies. The Board applied the intermediate step theorem, considering both causation and aggravation, and found that the veteran's PTSD caused obesity and disrupted REM sleep, which in turn substantially contributed to the obstructive sleep apnea. Therefore, service connection for obstructive sleep apnea secondary to PTSD was granted.

Rationale

Private medical opinion found PTSD caused obesity and disrupted REM sleep, leading to obstructive sleep apnea.; Board found private opinion probative and favorable, applying intermediate step theorem.; VA opinions were unfavorable or minimally probative.

Full Decision Text

Citation Nr: A26040946
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 250731-568011
DATE: April 30, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea is granted.

FINDING OF FACT

The Veteran's obstructive sleep apnea is caused by his service-connected posttraumatic stress disorder (PTSD).

CONCLUSION OF LAW

The criteria for service connection for sleep apnea have been met.? 38?U.S.C. §?1101, 1131; 38?C.F.R. §§?3.303, 3.304, 3.306, 3.310. 

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from January 1991 to January 1994 and from January 1997 to January 2000.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2025 decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ).  The Veteran filed a VA Form 10182 in July 2025.  

In the July 31, 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 April 2025 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his 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 on appeal 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

Service connection is?warranted?where the evidence of record?establishes?that an injury or disease resulting in a disability was incurred in the line of duty during active military service or, if an injury or disease pre-existing such service was aggravated thereby.? 38?U.S.C. §?1110, 1131; 38?C.F.R. §?3.303(a).??? 

Establishing service connection?generally requires?(1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability.? Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004);?see?also Caluza v. Brown, 7?Vet. App.?498, 506 (1995).??? 

Service connection may be?established?on a secondary basis for a disability which is due to or the result of service-connected disease or injury.? 38?U.S.C. §§?1110, 1131; 38?C.F.R. §§?3.303, 3.310.? In order to?prevail on the theory of secondary?service connection, there must be evidence of a current disability; evidence of a service-connected disability; and evidence?establishing?a connection between the service-connected disability and the current disability.? Wallin v. West,?11?Vet. App.?509, 512 (1998).??? 

Entitlement to service connection for obstructive sleep apnea.

The Veteran contends that he should be service connected for obstructive sleep apnea as secondary to his service-connected PTSD.  

The Board notes that the AOJ has previously conceded that the Veteran's claimed primary disability, (PTSD) is service-connected.  The AOJ also confirmed that the Veteran has been diagnosed with obstructive sleep apnea.  Therefore, the remaining issue before the Board is whether the Veteran's service-connected PTSD caused
 current disability; evidence of a service-connected disability; and evidence?establishing?a connection between the service-connected disability and the current disability.? Wallin v. West,?11?Vet. App.?509, 512 (1998).??? 

Entitlement to service connection for obstructive sleep apnea.

The Veteran contends that he should be service connected for obstructive sleep apnea as secondary to his service-connected PTSD.  

The Board notes that the AOJ has previously conceded that the Veteran's claimed primary disability, (PTSD) is service-connected.  The AOJ also confirmed that the Veteran has been diagnosed with obstructive sleep apnea.  Therefore, the remaining issue before the Board is whether the Veteran's service-connected PTSD caused or aggravated the Veteran's obstructive sleep apnea. 

The Veteran was afforded a VA examination in July 2023.  The July 2023 VA examiner noted that the Veteran's risk factors for sleep apnea include: male gender, advancing age, and elevated BMI.  The VA examiner opined that the Veteran's obstructive sleep apnea was less likely than not caused by the Veteran's service-connected condition.  The Board assigns minimal probative weight to the July 2023 opinion as it failed to discuss whether any of the Veteran's service-connected conditions may have caused the Veteran's obesity.

In December 2023, the Veteran was afforded another VA examination.  The VA examiner opined that it is less likely than not that the claimed condition is due to service as there is a lack of substantiating evidence supporting a nexus between the current diagnosis of severe obstructive sleep apnea and military service.  The examiner further noted that there was no documented diagnosis within the service treatment records. 

In July 2025, a private medical doctor provided a medical opinion.  The private doctor opined that the Veteran's obstructive sleep apnea was caused by service-connected PTSD as it disrupted the Veteran's REM sleep.  The private doctor also opined that the Veteran's PTSD caused the Veteran's obesity, which was another cause of the Veteran's obstructive sleep apnea.  The private doctor cited several journals and data supported studies with detailed analysis as to the etiology of the Veteran's obstructive sleep apnea.  The private doctor noted that large fat deposits in the neck do narrow the airway but REM sleep, which causes paralysis of the airway muscles and especially the tongue, are what cause obstructive sleep apnea to occur.  The private doctor therefore found that disruption of REM sleep was observed in patients suffering from PTSD, mood disorder, and tinnitus.  The Board finds that the examination is probative as it provided adequate rationale to support the positive nexus opinion.  

Obesity may be considered "an intermediate step" for service?connection if the evidence shows that a service-connected disability "caused the veteran to become obese" and the obesity caused by the service connected disability "was a substantial factor in causing" the current disability, and that the current disability "would not have occurred but for" the obesity caused by the service-connected disability."? VA Off. Gen. Couns. Prec. Op. 1-2017.? 

In?Walsh v. Wilkie, moreover, the Court further held that the Board needs to consider the obesity-intermediate step theorem predicated on aggravation where appropriate.? 32?Vet. App.?300 (2020).? Thus, the Court held that proper interpretation of G.C. Prec. Op. 1-2017 requires consideration of both causation and aggravation in its analytical framework: (1) whether the service-connected disability (caused the veteran to become obese/aggravated the veteran's obesity); (2) if so, whether the (obesity/aggravation of obesity) as a result of the service-connected disability was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for (obesity caused/obesity aggravated) by the service-connected disability.? If these questions are answered in the affirmative, then the current disability may be service connected on a secondary basis.? Walsh, 32?Vet. App.?300.?

The Board notes that the Veteran does have a current diagnosis of obstructive sleep apnea.  The Board notes that the private medical doctor opined that the Veteran's PTSD contributed to the Veteran's obesity.  The private doctor noted that obesity, which was caused by PTSD, was a factor in causing the Veteran's obstructive sleep apnea.  The Board also notes that the examiner found that the Veteran's PTSD also caused disruption in REM sleep, and therefore with obesity and the disrupted REM sleep the Veteran's airway was blocked during sleep, which resulted in obstructive sleep apnea.  The examiner noted that the Veteran's obstructive sleep apnea would not have occurred if it were not for the combination of obesity and disrupted
.?300.?

The Board notes that the Veteran does have a current diagnosis of obstructive sleep apnea.  The Board notes that the private medical doctor opined that the Veteran's PTSD contributed to the Veteran's obesity.  The private doctor noted that obesity, which was caused by PTSD, was a factor in causing the Veteran's obstructive sleep apnea.  The Board also notes that the examiner found that the Veteran's PTSD also caused disruption in REM sleep, and therefore with obesity and the disrupted REM sleep the Veteran's airway was blocked during sleep, which resulted in obstructive sleep apnea.  The examiner noted that the Veteran's obstructive sleep apnea would not have occurred if it were not for the combination of obesity and disrupted REM sleep, both caused by the Veteran's service-connected PTSD.  

The Board finds that there are both positive and negative opinions of record.  However, the Board finds that the private medical opinion is probative and favorable to the Veteran.  

Therefore, the claim for service connection for obstructive sleep apnea secondary to service-connected PTSD is granted.  

 

 

DONNIE R. HACHEY

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Counsel, H. Hailu

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.