Entitlement to service connection for obstructive sleep apnea (OSA) is granted.

Citation Nr: A26069988 Decision Date: 07/30/26 Archive Date: 07/30/26 DOCKET NO. 260604-668303 DATE: July 30, 2026 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is granted. FINDING OF FACT The Veteran's OSA is due to service-connected posttraumatic stress disorder (PTSD) with major depressive disorder (MDD) and diabetes mellitus, type II (DM II). CONCLUSION OF LAW The criteria for service connection for OSA as secondary to PTSD with MDD and DM II are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1968 to June 1976. This matter is on appeal from a June 2025 rating decision. In June 2026, the Veteran submitted a VA Form 10182, notice of disagreement, requesting Evidence Submission review by a Veterans Law Judge. The Board will consider evidence of record at the time of the June 4, 2025, rating decision notification letter and evidence submitted within 90 days of the June 12, 2026, submission date of the VA Form 10182. 38 C.F.R. § 20.303. Service Connection - Applicable Law and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may 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(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). However, a veteran can also establish service connection on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires (1) a current disability not already service-connected; (2) at least one service-connected disability; and (3) evidence that the nonservice-connected disability is either (a) caused by or (b) aggravated by (has any incremental increase in severity due to) a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); Spicer v. McDonough, 61 F.4th. 1360, 1363-65 (Fed. Cir. 2023); 38 C.F.R. § 3.310. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence persuasively favors the claim or is in approximate balance, with the Veteran prevailing in either event, or whether the evidence persuasively weighs against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (2021). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Lynch, 21 F.4th, at 780-81. Factual Background and Analysis The Veteran seeks service connection for his OSA as secondary to his service-connected PTSD with MDD and/or DM II with renal manifestations, kidney disease, and diabetic dermatitis. In this case, the AOJ has favorably found that the Veteran was diagnosed with sleep apnea. Also, the Veteran is service connected for PTSD with MDD and/or DM II with renal manifestations, kidney disease, and diabetic dermatitis. Thus, the third element of secondary service connection, i.e., a nexus between the service-connected disability and nonservice-connected disability/ites, is the only element at issue here. On the issue of nexus, the record contains a May 2026 private opinion - submitted in June 2026 within the appropriate evidence window - which in favor of the claim, and a June 2025 VA opinion against the claim. The June 2025 VA examiner opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's PTSD with MDD. The rationale was as follows: "After a thorough review of the available medical evidence and literature, there is no established medical nexus between the diagnosed obstructive sleep apnea (OSA) and the service-connected post-traumatic stress disorder (PTSD). While some research has identified an association between PTSD and sleep disturbances, no definitive causal relationship has been demonstrated between PTSD and the development of OSA." The examiner further stated that the link between OSA and PTSD "remains unclear" and that the Veteran's condition is/are due to a medical/mechanical breakdown(s) of the associated organ systems and not due to an exposure event. The May 2026 private examiner opined that it was at least as likely as not that the Veteran's obstructive sleep apnea developed secondary to his service-connected PTSD with MDD and its associated symptom. The rationale is extensive and only the most salient points will be outlined as follows: Studies show that patients with mental health conditions, such as anxiety disorders, depressive 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. Abnormalities of REM sleep cause hypotonia of the muscles in the upper airway, which creates a functional obstruction of the upper airways, resulting in OSA. Furthermore, chronic activation of stress hormones (hypothalamic-pituitary-adrenal axis activity) caused by anxiety is well known to lead to a neural sensitization leading to upper airway dysfunction, which can predispose an individual to OSA. This is demonstrated in "Corticotropin-Releasing Factor. Norepinephrine. and Stress, published in Biological Psychiatry," which shows that the response to stress implicates two systems that both play a key role in physiological responses to stress by promoting arousal in the corticotropin-releasing hormone (CRH) system and the LC-autonomic nervous (AN) system. This concept is reinforced in "Sympathetic Activity and Hypothalamo- Pituitary-Adrenal Axis (HPA) Activity During Sleep in Post-traumatic Stress Disorder: A Study Assessing Polysomnoraphy with Simultaneous Blood Sampling published in Psychoneuroendocrinology, which suggests that HPA axis activity is related to sleep fragmentation in PTSD, and activity of the sympathetic nervous system is increased during sleep in PTSD. This is significant because [the Veteran] has a protracted history of PTSD-related symptoms dating back to his military service and deployment to Vietnam with symptoms to include recurrent distressing dreams and memories, hypervigilance, an exaggerated startle response, sleep disturbances, depressed mood, anxiety, suspiciousness, weekly or less frequent panic attacks, and chronic sleep impairment, per the 02/07/2022 Initial PTSD DBQ, which all likely have had a profound impact on his sleep architecture. The private examiner went on to discuss and cite eight other medical studies that address the relationship between OSA and PTSD. The examiner further opined that, "after a review of the pertinent records, his medical history, and the above-cited, peer-reviewed medical literature, it is my professional opinion that it is at least as likely as not that [the Veteran's] obstructive sleep apnea developed secondary to his service-connected Diabetes Mellitus type II (DM11) with renal manifestations/kidney disease and diabetic dermatitis and its associated sequelae." The private examiner then went on to discuss and cite to several medical studies that addressed relationship between OSA and DM II, particularly those with significant diabetes-related complications, such as the Veteran: "Interactions between and Shared Molecular Mechanisms of Diabetic Peripheral Neuropathy and Obstructive Sleep Apnea in Type 2 Diabetes Patients" supported the conclusion that DPN played a significant role in the pathogenesis and severity of OSA by weakening respiratory control and upper airway stability, especially in patients with longstanding or poorly controlled diabetes. "Clinical presentation and Diagnosis of Obstructive Sleep Apnea in Adults and Obstructive Sleep Apnea and Type 2 Diabetes in Older Adults" both also show that those with longstanding DM are at an increased risk at developing OSA. "Insulin Resistance. Hypendycemia. and Risk of Developing Obstructive Sleep Apnea in Men and Women in the United States and Obstructive Sleep Apnea and Type 2 Diabetes: Is There a Link?" shows that insulin resistance may play an important role in the pathogenesis of OSA, and pharyngeal collapsibility during sleep is elevated in insulin-resistant females with morbid obesity states "insulin resistance may play a significant role in the pathogenesis of OSA by generating requisite elevations in pharyngeal collapsibility. Once sleep apnoea develops, insulin resistance can further increase upper airway collapsibility and perpetuate a vicious cycle of sleep apnoea progression." The private examiner acknowledged that the Veteran had additional risk factors for OSA, including obesity, but concluded: "Even after taking into consideration his personal risk factors for OSA, including his of obesity, it remains my opinion that it is at least as likely as not that the Veteran's OSA developed secondary to his service connected PTSD with MDD and DM II and their associated sequalae." The Board finds the May 2026 VA opinion to be significantly more probative than the June 2025 VA opinion. Indeed, the private medical professional personally conducted a thorough review of the Veteran's pertinent medical and personnel records, including relevant documents contained in his complete VA claims file. She also cited extensively to medical literature and provided a well-reasoned, well-supported rationale for her findings. See Nieves-Rodriguez v. Peake, 22 Vet. App. App. 295, 301-02 (2008). On the other hand, the June 2026 VA examiner did not cite to any supporting data or medical studies to support his findings and provided ambiguous and equivocal conclusions (e.g., finding that there was an association between PTSD and sleep disturbance but "the link between OSA and PTSD remains unclear."). For these reasons, the Board finds the May 2026 private opinion to be the most probative of record. In short, the Veteran has been diagnosed with OSA; he is currently service connected for PTSD with MDD, and DM II (along with several complications of such); and the most probative medical evidence of record weighs in favor of a finding that his OSA developed as secondary to these service connected disabilities. Therefore, resolving any remaining reasonable doubt in the Veteran's favor, the evidence of record sufficiently supports entitlement to sleep apnea as secondary to service-connected PTSD with MDD and DM II. The appeal is granted on a secondary basis. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. [SIGNATURE ON NEXT PAGE] JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board O'Donnell, Holly H. 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.