Sleep Apnea Claimed as Secondary to PTSD

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 claimed as secondary to posttraumatic stress disorder (PTSD) is one of those claims. In the Board of Veterans' Appeals decisions we have indexed since 2019, it shows up in 3,123 issues. Only one pairing we index shows up in more.

Already rated for PTSD? The free Claim Map shows sleep apnea and the other conditions the Board has seen claimed with PTSD.

What a secondary claim needs

Here is the rule on secondary conditions, from the middle of its first sentence through the next one.

… disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.

Proximately due to means the first condition led to the second. So three things have to be in your file. A diagnosis of sleep apnea. PTSD that is already service connected. And a medical opinion that ties the two together and says why.

If your PTSD isn't service connected yet, there's nothing for the sleep apnea to attach to. That isn't a reason to wait. File both, and say in writing that the sleep apnea is claimed as secondary to the PTSD. The sleep apnea question then rides on the PTSD question and gets answered after it.

Sleep apnea can also be claimed as related to service on its own facts. The rule on diseases diagnosed after discharge allows it when all the evidence establishes the disease began in service. One claim can raise both routes.

Aggravation is a different question

The rule on secondary conditions has a second route, and it asks something else. The first route asks whether PTSD brought the sleep apnea on. The second asks whether PTSD made sleep apnea you already had worse. Here is its first sentence.

Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected.

Only the increase is service connected, and only the part of it that isn't the disease taking its own course.

That paragraph goes on to require a baseline. A baseline is medical evidence of how bad the sleep apnea was before the PTSD started making it worse. Or it can be the earliest medical record made after the worsening began and before the evidence of how bad it is now. Without a baseline from one of those two windows, the VA will not concede aggravation. The first route doesn't need one. Choose the route your records can carry.

How sleep apnea is rated

Sleep apnea has its own diagnostic code, 6847, in the part of the VA's rating schedule for breathing conditions. It sets out four steps, written as 0, 30, 50 and 100. Those are percentages.

The bottom step is "Asymptomatic but with documented sleep disorder breathing", meaning no symptoms but a record of the breathing problem. The next one up is "Persistent day-time hypersomnolence", which is daytime sleepiness that doesn't let up. Above that is "Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine". The top step is chronic respiratory failure with carbon dioxide retention or cor pulmonale. Cor pulmonale is strain on the right side of the heart caused by a lung or breathing problem. A case that requires a tracheostomy, a breathing opening cut into the neck, is rated there too.

None of those turn on how tired you feel. The bottom step turns on a document, and that document is a sleep study. Every step starts from it. Without one there's no diagnosis to rate and nothing to connect to your PTSD. The 30 step turns on a symptom that persists. The 50 step turns on a breathing device being required, so the record of the prescription and the machine carries it. Which step fits you is the rater's call on your records, not mine.

What our counts show

This pairing has its own page, sleep apnea secondary to PTSD. Since 2019, the Board granted 593 of those 3,123 issues and denied 507, which comes to 54 percent granted of the ones it decided.

Since 2019 the Board also sent 1,926 of those issues back for more work, which is 62 percent of them. More of these claims go back than get answered either way. A remand isn't a yes and it isn't a no. The Board sends the claim back to the regional office for a new exam or a missing record, and it's decided again later. If you are appealing this claim, plan on the long version of it.

Across every year we have indexed, the pairing runs to 4,908 issues at 48 percent granted of the ones decided.

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.

One more count, off the sleep apnea page. Across every year we have indexed, 92 percent of the granted sleep apnea issues sit in a decision that mentions a medical opinion. The share for the denied ones is a point lower. A mention is not a reason for the outcome. The count can't see whether the opinion was for the claim or against it, or which issue in the decision it was about.

Since 2019 we have indexed 74,459 PTSD issues and 36,121 sleep apnea issues, counting every theory and not just this pairing.

Add PTSD in the Claim Map and sleep apnea comes up with its counts since 2019.

What a doctor would have to find

A claim here needs a doctor to find that the PTSD, its medicine, or weight gain from them led to or worsened the sleep apnea. It isn't a finding of ours, and I'm not telling you it's true in your case. That one is for your doctor.

What the Board reads is the opinion. An opinion that says the two are connected and stops there leaves the rater nothing to weigh. One that says how it happened in you, and points at what in your records shows it, does the work the rule asks for. Ask your doctor to write down what they reviewed, what they found in it, and the reasoning behind their conclusion.

The phrase to ask for is at least as likely as not. Step 1 covers that letter and the records that go with it.

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 sleep study 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, or get a copy of the one you already had. That's the diagnosis.
3. Check that your PTSD is service connected. If it is, name it in the claim as the condition the sleep apnea is secondary to.
4. Ask your doctor for the opinion, reasoning included.
5. If your claim is that PTSD made sleep apnea you already had worse, find the earliest record of it you can. That's the baseline.
6. File the claim with all of it attached, within a year of your intent to file.

Step 4 is the presumptive routes, where you don't have to prove the link at all. I'm not your representative, and this isn't legal advice.