What Sleep Apnea Gets Claimed Secondary To

Step 3 of the method is secondary conditions. A secondary condition is one that grew out of a condition the VA already rates.

Sleep apnea is unusual on this site. Veterans rarely ask what grows out of it. They ask what it grew out of, because the rating turns on one line in the schedule and that line is worth reaching.

New here? The free page on sleep apnea shows what the Board granted, denied and sent back, and links the decisions themselves. Nothing to sign up for.

Why the rating matters

Sleep apnea has four steps, and the jump between two of them is the reason this claim gets filed.

• Documented sleep disorder breathing with no symptoms is 0.
• Persistent day-time sleepiness is 30.
• Needing a breathing assistance device, such as a CPAP machine, is 50.
• Chronic respiratory failure with carbon dioxide retention, cor pulmonale, or a tracheostomy is 100.

Those are percentages. A veteran on a CPAP machine sits at the 50 step. The VA combines ratings rather than adding them, and a 50 moves a combined rating more than most single conditions do.

Every step above the bottom one rests on a diagnosis, and the bottom step already asks for documented sleep disorder breathing. In practice that means a sleep study in your records. Without one there is nothing for the schedule to rate.

What a secondary claim needs

Here's the rule on secondary conditions, starting in the middle of its first sentence.

… disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.

Proximately due to means the first condition led to the second. Three things have to be in your file. A diagnosis of the sleep apnea. A first condition that is already service connected. And a medical opinion tying the one to the other that says why.

A claim here needs a doctor to find that the first condition led to or worsened the sleep apnea. It isn't a finding of ours. Whether it's true for you is a question for your doctor.

The rule holds a second route, aggravation, for sleep apnea you already had that the first condition made worse. That route needs a baseline, meaning medical evidence of how bad the sleep apnea was before the first condition started making it worse.

What a nexus letter is

The medical opinion above has a common name. A nexus letter is a letter from a doctor saying one condition led to or worsened another, and saying why. Nexus means link. It's the part of a secondary claim veterans ask about most, and the part the Board writes about most when it explains a denial.

We don't write these and we don't offer one. What follows is what the Board's own decisions show it reading for.

• The reasoning, above everything. A conclusion with nothing behind it is what the Board discounts most often. The phrase "at least as likely as not" is the standard being met, not an argument on its own.
• What the doctor looked at. An opinion reads stronger when it names the records behind it, including the sleep study and the history of the first condition.
• Which route it argues. Airway, weight and medication, or pain and sleep. A letter that names the mechanism gives a rater something to follow.
• Aggravation, when that's the claim. If the sleep apnea came first, the letter has to speak to how bad it was before the other condition made it worse, because the rule asks for that baseline.

The airway route shows what that looks like. For sleep apnea secondary to asthma, or secondary to sinusitis or rhinitis, an opinion carries further when it explains how the airway condition affects breathing during sleep, rather than noting that a veteran has both and stopping there. The Board decided 153 issues on sleep apnea secondary to asthma and granted 46 percent of them.

The standard itself is 38 CFR 3.102. When the evidence for and against is in approximate balance, the benefit of the doubt goes to the veteran. That's where the phrase comes from and why it appears in so many opinions.

What the Board has seen it claimed with

Ten conditions carry enough decided claims to read. Each links to its own page of counts.

• PTSD: 4,908 issues, 48 percent granted of the ones decided.
• Depression, anxiety and other mental health conditions: 2,078 issues, 53 percent.
• Diabetes: 806 issues, 31 percent.
• Sinusitis: 568 issues, 50 percent.
• High blood pressure: 521 issues, 34 percent.
• Rhinitis and allergies: 474 issues, 53 percent.
• Asthma: 457 issues, 46 percent.
• A lower back condition: 430 issues, 48 percent.
• Heart disease: 304 issues, 29 percent.
• A knee condition: 262 issues, 60 percent.

granted more oftengranted less often thicker means claimed more oftenpairing not involving tinnitus

Tap a line to read what that pairing has to show.

Two things those counts are not. Every decision counted here is an appeal, so the regional office decided the claim first and the veteran disagreed. These are not the odds on a first claim. And past decisions don't predict yours. A Board decision binds only the case it decided.

Which way round the claim runs

A pairing has two directions, and they are different claims. Sleep apnea caused by your diabetes is one. Diabetes caused by your sleep apnea is the other. The Board has heard both, and for most of these pairings it granted the second far more often than the first.

• Sleep apnea secondary to diabetes: 806 issues, 31 percent granted of the ones decided. The other way round, diabetes secondary to sleep apnea: 117 issues, 59 percent.
• Sleep apnea secondary to heart disease: 304 issues, 29 percent. The other way round, heart disease secondary to sleep apnea: 117 issues, 70 percent.
• Sleep apnea secondary to migraines: 196 issues, 34 percent. The other way round, migraines secondary to sleep apnea: 110 issues, 60 percent.
• Sleep apnea secondary to high blood pressure: 521 issues, 34 percent. The other way round, high blood pressure secondary to sleep apnea: 357 issues, 51 percent.
• Sleep apnea secondary to depression and anxiety: 2,078 issues, 53 percent. The other way round, depression and anxiety secondary to sleep apnea: 80 issues, 48 percent.

Mental health is the one that runs the other way, which is worth noticing. It means this isn't a rule about directions. It's what the Board did with the claims it heard, and the four where the gap is wide are all conditions medicine links to sleep apnea in both directions.

Which direction fits you isn't a counting question. It depends on which condition the VA already rates and what your records show came first. That's a question for your doctor and your file, not for a table.

The routes are not one thing. A breathing route, where a blocked or inflamed airway is the argument, covers sinusitis, rhinitis and asthma. A weight and medication route runs through the mental health conditions. A body route, where pain and how you sleep are the argument, covers the back and the knee. Which one fits you is a medical question, not a counting one.

Want the whole picture for sleep apnea? The Sleep Apnea Pack puts the Board's counts, the rating criteria and the decisions to read in one file. No account and nothing to fill in.

The claim the Board sees most

Sleep apnea claimed as secondary to PTSD is the largest pairing on this site. It has its own article, sleep apnea claimed as secondary to PTSD, with the rating ladder and what the Board looked at.

What our counts show

Sleep apnea has its own page of Board counts, sleep apnea. Since 2019 veterans raised 36,121 issues about it, and the Board granted 50 percent of the ones it decided.

On that page, 92 percent of granted issues and 91 percent of denied ones sit in decisions that mention a medical opinion. A mention is not a reason for the outcome. It shows how often this question turns on what a doctor wrote, which is the part of the file you control.

What to do

1. Send VA an intent to file first. If your complete claim reaches VA within a year of it, VA counts the claim as filed on the day the intent to file arrived. It doesn't have to name a condition, so you don't need the diagnosis or the opinion to send it. It doesn't work for a supplemental claim, where you add evidence and ask VA to decide again.
2. Get the sleep study in writing. Ask for the report itself, not the summary line in a visit note.
3. Check which of your conditions is already service connected, and name that one in the claim as the condition the sleep apnea is secondary to.
4. Ask your doctor for the reasoning, not only the conclusion. How it happened in you, and what in your records shows it. The phrase to ask for is at least as likely as not. Step 1 covers that letter.
5. If you use a CPAP machine, put that in the claim, along with when it was prescribed and who prescribed it.
6. File the claim with all of it attached, within a year of your intent to file.

The nine steps lays out the rest. I'm not your representative.