Sleep apnea secondary to PTSD: how the claim works

Sleep apnea is one of the most common conditions veterans claim, and one of the most commonly denied. The usual reason is simple: most veterans were never diagnosed while they were in uniform, so a direct claim has nothing in the service record to point to. For many of them, the stronger path is a secondary claim: showing that a condition VA has already service connected, such as PTSD, caused or worsened the sleep apnea.

How VA rates sleep apnea today

Sleep apnea is rated under Diagnostic Code 6847 in 38 CFR § 4.97. As of this writing, every claim is still decided under these criteria:

Rating	Current criteria (DC 6847)
100%	Chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires a tracheostomy
50%	Requires use of a breathing assistance device such as a CPAP machine
30%	Persistent daytime hypersomnolence
0%	Asymptomatic but with a documented sleep disorder breathing

Why PTSD and sleep apnea travel together

Research on post-9/11 veterans has found that those with PTSD screen at high risk for obstructive sleep apnea far more often than you'd expect, and the relationship is an active area of study. The medical reasoning in a secondary opinion usually draws on some combination of these:

• Sleep disruption and hyperarousal. PTSD fragments sleep and changes sleep architecture, which is tied to breathing instability during sleep.
• Medication effects. Some medications used for PTSD, anxiety, pain and sleep can promote weight gain or relax the upper-airway muscles.
• Weight gain as an intermediate step. Obesity itself is not a disability for VA purposes, but VA's General Counsel has recognized that a service-connected condition can cause weight gain that in turn causes or worsens another condition. The opinion has to explain that chain carefully.
• Aggravation. Even when sleep apnea has other causes, PTSD and its treatment can make it worse than it would otherwise be. That is a separate question VA must answer.

PTSD isn't the only possible link. Chronic rhinitis or sinusitis, and long-term opioid therapy for a service-connected pain condition, can also be part of the picture, depending on the record. Our secondary & associated conditions page covers more of these connections.

What the evidence needs to show

1. A current diagnosis confirmed by a sleep study. VA expects sleep apnea to be confirmed by a sleep study, not only by symptoms.
2. A service-connected condition it relates to, such as PTSD.
3. A medical opinion that explains, at least as likely as not, how that condition caused or aggravated the sleep apnea, with reasoning tied to your record and the medical literature.

The opinion is where most secondary sleep apnea claims are won or lost. A one-line conclusion carries little weight. An opinion that walks through the mechanism, addresses both causation and aggravation, and deals honestly with other risk factors is the kind a rater can rely on. Here's what makes a Nexus Letter hold up.

References

1. 38 CFR § 4.97, Diagnostic Code 6847 (sleep apnea syndromes). LII
2. 38 CFR § 3.310, Disabilities that are proximately due to, or aggravated by, service-connected disease or injury. LII
3. VA Office of General Counsel, VAOPGCPREC 1-2017: obesity as an intermediate step in secondary service connection.
4. Walsh v. Wilkie, 32 Vet. App. 300 (2020).
5. Colvonen PJ, Masino T, Drummond SPA, et al. Obstructive sleep apnea and posttraumatic stress disorder among OEF/OIF/OND veterans. J Clin Sleep Med. 2015;11(5):513-518.
6. Proposed rule, Schedule for Rating Disabilities: The Respiratory System; Ear, Nose, and Throat; and Audiology. Federal Register, Feb. 15, 2022 (FR Doc. 2022-02049).

This article is general information, not medical or legal advice. Every claim depends on its own record.