SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran, an Army Veteran who served from July 2009 to November 2015, including a deployment to Afghanistan where he earned the Afghanistan Campaign Medal and Combat Infantryman Badge, appeals the denial of service connection for sleep apnea, claimed as secondary to his service-connected PTSD. The Agency of Original Jurisdiction (AOJ) denied the claim in March 2025, but this decision is being reviewed on the merits as new and relevant evidence was found. The Board is bound by the AOJ's favorable finding of a current sleep apnea disability and the existing service connection for PTSD. The core issue is whether the sleep apnea is proximately due to or the result of the service-connected PTSD. The Board reviewed three VA medical opinions and one private medical opinion. The VA opinions were mixed: one in November 2023 found sleep apnea less likely than not caused by toxic exposure, citing lack of scientific evidence linking specific exposures to sleep apnea. A February 2024 VA opinion attributed sleep apnea primarily to excess weight, noting PTSD is not a direct cause according to medical literature, though it can cause sleep disturbances. A December 2024 VA opinion stated sleep apnea etiologies are not clinically related to PTSD. However, a private medical opinion in October 2024, citing studies on the comorbidity and bidirectional relationship between OSA and PTSD, opined that the Veteran's sleep apnea is at least as likely as not caused by his service-connected PTSD, directly contradicting the VA's findings. The Board found the evidence in approximate balance, ultimately resolving the doubt in the Veteran's favor, granting service connection for sleep apnea secondary to PTSD.

Rationale

AOJ favorable finding of current sleep apnea; Veteran is service-connected for PTSD; Evidence in approximate balance between VA and private opinions; Private opinion found competent and credible, linking sleep apnea to PTSD

Full Decision Text

Citation Nr: A26040982
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 260303-648991
DATE: April 30, 2026

ORDER

Service connection for sleep apnea, to include as secondary to service-connected post-traumatic stress disorder (PTSD), with unspecified depressive disorder, is granted.

FINDING OF FACT

The evidence is in approximate balance on whether the Veteran's sleep apnea is secondary to his service-connected PTSD.

CONCLUSION OF LAW

The criteria for service connection for sleep apnea, to include as secondary to service-connected PTSD, 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 honorably in the United States Army from July 2009 to November 2015. The Board of Veterans' Appeals (Board) thanks the Veteran for his service to our country, including deployment to Afghanistan in support of Operation Enduring Freedom, for which he was awarded the Afghanistan Campaign Medal with 3 Campaign Stars and the Combat Infantryman Badge, among others.

This matter comes before the Board on appeal from a March 2025 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ), which found that new and relevant evidence had been received and reconsidered and denied the claim for sleep apnea based on the evidence of record at the time of that decision. As new and relevant evidence has been found by the AOJ, the claim will be addressed on the merits below. 38 C.F.R. §§ 3.102, 3.104.

In the March 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the March 2025 AOJ decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

Service connection for sleep apnea, to include as secondary to service-connected PTSD.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence establishes the disease was incurred in service. 38 C.F.R. § 3.303(d).

Generally, to prevail on the issue of service connection, the evidence must show: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the persistent disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

A disability also may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disability or if it is aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439 (1995).

Here, the Veteran contends that his current sleep apnea disability is proximately due to or the result of his service-connected PTSD.

First, the AOJ in the March 2025 rating decision made a favorable finding that the Veteran had a current sleep apnea disability. The Board notes that it is bound by the favorable finding made by the AOJ in the April 2025 rating decision. 38 C.F.R. § 3.104(c). 

Additionally, the Board notes that the Veteran is service-connected for PTSD.

Thus, the question for the Board is whether the Veteran's current sleep apnea disability is proximately due to or the result of his service-connected PTSD.

After review of all of the evidence, lay and medical, the Board finds that the persuasive evidence of record indicates the Veteran's sleep apnea is secondary to his service-connected PTSD.

The Veteran has had three VA medical opinions regarding the etiology of his sleep apnea: November 2023, February 2024, and December 2024. 

The November 2023 VA medical opined that the Veteran's sleep apnea is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments
 service-connected for PTSD.

Thus, the question for the Board is whether the Veteran's current sleep apnea disability is proximately due to or the result of his service-connected PTSD.

After review of all of the evidence, lay and medical, the Board finds that the persuasive evidence of record indicates the Veteran's sleep apnea is secondary to his service-connected PTSD.

The Veteran has had three VA medical opinions regarding the etiology of his sleep apnea: November 2023, February 2024, and December 2024. 

The November 2023 VA medical opined that the Veteran's sleep apnea is less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran. The VA examiner stated that "there is no objective medical or scientific evidence to show that a specific exposure event experienced by the claimant experienced during service in Southwest Asia can produce and/or aggravate recurrent collapse of the velopharyngeal and/or nasopharyngeal airway during sleep." The examination report indicated that the Veteran's current symptoms are headaches, daytime drowsiness, and "jerking/twitching" while sleeping. 

The February 2024 VA medical opined that the Veteran's sleep apnea is more likely from his excess weight than from PTSD. The VA examiner cited to medical literature, noting that "obstructive sleep apnea occurs when the muscles in the back of the throat relax. When the muscles relax, your airway narrows or closes as you breathe in." Additionally, the VA examiner discussed the Veteran's excess weight and sleep apnea, stating "one common cause of obstructive sleep apnea is excess weight. The Veteran has struggled with his weight and has been overweight or obese since at least 2016. In April 2016 he was referred to the MOVE! program for a BMI of 28.9." Notably, the VA examiner did acknowledge that PTSD can cause sleep disturbances but noted that "the medical literature is silent for PTSD as a cause of obstructive sleep apnea." 

In December 2024, the Veteran was provided with an additional VA examination and medical opinion. The examination report noted that the Veteran reported onset of sleeping issues beginning around 2014. The VA examiner opined that "per NIH, the claimed Sleep apnea syndrome, diagnosed as obstructive sleep apnea has etiologies that are not clinically related to the veterans SC posttraumatic stress disorder with unspecified depressive disorder." No additional rationale was provided. 

In October 2024, the Veteran was provided with a private medical opinion from a private examiner. The private examiner reviewed the Veteran's medical history, including medical records, military STRs, and the Veteran's self-reported symptoms. The private examiner discussed his symptoms in service as well as post service. The private examiner noted that "studies show that patients with mental health conditions, such as anxiety disorders and PTSD, are more likely to be diagnosed with OSA than the general population. Anxiety and stress are associated with a fragmented pattern of REM sleep." Additionally, the private examiner cited to medical literature noting that "OSA and PTSD are often comorbid conditions with each other and how OSA prevalence is higher among PTSD sufferers that those without, likely with a bidirectional effort between the two. They discuss that there is a significant co-prevalence has been found between OSA and PTSD." The private examiner cited various articles to support this conclusion. Additionally, the private examiner commented on the February 2024 VA medical opinion, noting that the articles that the private examiner provided contradict the conclusion of the VA examiner, which stated that the Veteran's sleep apnea is more likely from his excess weight than from PTSD. Ultimately, after reviewing the Veteran's records, medical history, and medical literature, the private examiner opined that the Veteran's sleep apnea is at least as likely as not caused by his service-connected PTSD.  To support this, the examiner discussed the Veteran's history of symptoms and risk factors and stated that "medical evidence shows that PTSD patients can exhibit anatomical changes within the brain that may contribute to OSA. The medical evidence also shows that PTSD patients have almost three times the incidence of OSA versus patients without PTSD regardless of other OSA risk factors."

The Board has considered the Veteran's various VA medical opinions and lay statements, and finds that the evidence is in approximate balance on whether service connection is warranted. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). There is medical evidence indicating that the Veteran's sleep apnea is not secondary to his service-connected PTSD as shown by the February 2024 VA medical opinion. The Board also notes that there is medical evidence indicating the Veteran's sleep apnea is secondary to his service-connected PTSD, as shown
 the brain that may contribute to OSA. The medical evidence also shows that PTSD patients have almost three times the incidence of OSA versus patients without PTSD regardless of other OSA risk factors."

The Board has considered the Veteran's various VA medical opinions and lay statements, and finds that the evidence is in approximate balance on whether service connection is warranted. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). There is medical evidence indicating that the Veteran's sleep apnea is not secondary to his service-connected PTSD as shown by the February 2024 VA medical opinion. The Board also notes that there is medical evidence indicating the Veteran's sleep apnea is secondary to his service-connected PTSD, as shown by the October 2024 private medical opinion. Additionally, the Board finds the private medical opinion to be competent and credible, and as such, is entitled to significant probative weight. See Prejean v. West, 13 Vet. App. 444 (2000) (noting that the credibility and weight to be attached to medical opinions are within the province of the Board); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion).

Accordingly, for the reasons set forth above, the Board finds the evidence is in approximate balance on whether the Veteran's sleep apnea is secondary to his service-connected PTSD. Upon resolution of all reasonable doubt in the Veteran's favor, service connection is warranted.

 

H. SEESEL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Dourmashkin, Mark W.

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.