Sleep Apnea Secondary to PTSD: Building the 38 CFR 3.310 Nexus

Veterans assume sleep apnea diagnosed years after discharge cannot be service connected, especially when nobody documented snoring in service. The secondary path does not care about either. When PTSD is already recognized, 38 CFR 3.310 asks only whether the apnea is at least as likely as not caused or aggravated by it, and the published research on treatment-seeking veterans gives your doctor real footing to say so.

Veterans often assume that sleep apnea diagnosed years after discharge cannot be service connected, especially when nobody documented snoring while you were in. The secondary path does not care about either of those things. When PTSD is already recognized, 38 CFR 3.310 asks only whether the apnea is at least as likely as not caused or aggravated by it. The published research on treatment-seeking veterans gives your doctor real footing to say so.

Why this pairing is often overlooked

Obstructive sleep apnea and PTSD travel together far more often than chance would explain. When PTSD is already recognized and sleep apnea develops or grows worse, you can claim the sleep apnea as secondary under 38 CFR 3.310. This article explains the three parts of that claim and the research that supports the link.

What secondary service connection requires

Under 38 CFR 3.310, a condition that is proximately due to, the result of, or aggravated by a recognized condition can itself be recognized. A secondary sleep apnea claim has three parts:

1. A current diagnosis of obstructive sleep apnea, confirmed by a sleep study.
2. An already recognized primary condition, here PTSD.
3. A medical link saying the sleep apnea is at least as likely as not caused or aggravated by the PTSD.

The diagnosis comes from a sleep study that measures your apnea hypopnea index. The primary condition is your existing PTSD award. The nexus is the medical opinion, and the research below gives your doctor a basis for it.

What the research shows

A 2015 study by Colvonen and colleagues in the Journal of Clinical Sleep Medicine looked at veterans of Iraq and Afghanistan who were seeking PTSD treatment. The findings were notable:

• About 69 percent of these veterans screened at high risk for obstructive sleep apnea.
• Among those who went on to a sleep study, roughly 78 percent had results consistent with sleep apnea.
• As PTSD symptom scores rose, the chance of screening high risk for sleep apnea rose with them. A 10 point increase in PTSD score was tied to about a 40 percent higher chance of a high risk screen.

The authors noted that the usual predictors of sleep apnea, such as older age and higher body weight, did not fully explain the pattern in this younger group. That points toward the PTSD itself playing a role. They recommended that sleep apnea screening become a standard part of care for younger veterans with PTSD.

You do not have to prove the biology yourself. A published study like this gives your treating doctor a footing to say your sleep apnea is connected to your PTSD.

How to document the claim

1. Get the sleep study. A diagnosis with the apnea hypopnea index is the anchor of the claim.
2. Ask your doctor for a brief opinion. The useful phrasing is that your sleep apnea is at least as likely as not caused or aggravated by your PTSD. Hand the doctor the Colvonen study as supporting literature.
3. Describe the timeline. On VA Form 21-4138, note when the PTSD began, when the sleep problems followed, and how they have continued.
4. File the sleep apnea claim and reference the PTSD that VA already recognizes.

When aggravation applies

If you had mild sleep apnea that grew worse as your PTSD worsened, that is aggravation, and 38 CFR 3.310 covers it. Ask the doctor to address whether the PTSD made an existing sleep apnea problem worse, not only whether it caused it.

How sleep apnea is rated

Sleep apnea is evaluated under diagnostic code 6847. A rating of 50 percent applies when the condition requires use of a breathing assistance device such as a CPAP machine. Keep your treatment records, including the CPAP prescription, because they drive the rating.

This is educational. It is not legal or medical advice. A VA accredited representative can help you frame a secondary claim, and your own doctor is the right person to write the nexus.

Sources

• 38 CFR 3.310 (secondary service connection and aggravation)
• Colvonen et al., Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans (J Clin Sleep Med 2015)
• 38 CFR 3.102 (benefit of the doubt)
• VA Form 21-4138, Statement in Support of Claim

Before you file the secondary sleep apnea claim, ask

• Is the diagnosis anchored by a sleep study with an apnea hypopnea index in the file, not just a report of snoring and fatigue?
• Is the already recognized primary condition, here PTSD, identified by name in the claim?
• Does the medical opinion use "at least as likely as not," and does it address aggravation as well as causation (38 CFR 3.310 covers both)?
• Did I hand the doctor the supporting literature, such as the Colvonen 2015 study, instead of expecting them to research it?
• Is the timeline, PTSD first, sleep problems after, described in my own words on VA Form 21-4138?

Related on this site

• How VA rates PTSD (DC 9411)
• Sleep apnea condition guide
• PTSD condition guide
• Building your evidence: what VA looks for and how to organize it