VA Sleep Apnea Ratings: CPAP, the 50 Percent Rule, and Proposed Changes

Most veterans assume the sleep apnea rating turns on how severe the apnea is. Under the current schedule it mostly turns on treatment: the 50 percent level is written around the required use of a breathing assistance device, not around symptom severity.

How VA rates sleep apnea

Sleep apnea is rated under diagnostic code 6847 in 38 CFR 4.97, the respiratory schedule. There are four levels:

• 0 percent: a documented sleep disordered breathing but no symptoms.
• 30 percent: persistent daytime hypersomnolence (you are sleepy during the day no matter how much you rest).
• 50 percent: requires the use of a breathing assistance device such as a CPAP machine.
• 100 percent: chronic respiratory failure with carbon dioxide retention or cor pulmonale, or the condition requires a tracheostomy.

How the 50 percent rule works

Here is the point that drives most sleep apnea claims: the 50 percent level is written around the required use of a breathing assistance device, and a CPAP is only the most common example. The regulation says a device such as a CPAP machine, so the CPAP is an example, not a requirement. A BiPAP, an APAP, or a prescribed oral appliance (a mandibular advancement device fitted to hold your airway open during sleep) satisfies the same criterion. If a sleep study diagnoses obstructive sleep apnea and a doctor prescribes any of these devices to treat it, the criteria for 50 percent are met by the requirement to use the device. It does not matter how well the device controls your symptoms. The rule turns on the need for it. That is why a correctly documented prescription, for a CPAP or for an oral appliance, is usually worth a 50 percent evaluation under the current schedule. The Board has granted 50 percent for veterans who could not tolerate a CPAP and used a prescribed oral appliance instead.

Getting it service connected

You can establish sleep apnea two ways:

• Directly, if it began in service or symptoms (loud snoring, witnessed apneas, daytime sleepiness) were documented during service.
• Secondarily, if a service connected condition caused or aggravated it (38 CFR 3.310). Common paths include sleep apnea secondary to PTSD, or secondary to weight gain driven by a service connected condition or its medications. Research has examined the strong overlap between obstructive sleep apnea and PTSD, which supports a well reasoned nexus opinion.

A diagnosis almost always needs a sleep study (polysomnography or an approved home study). A secondary claim also needs a nexus opinion linking the apnea to the service connected condition.

Proposed changes worth watching

VA has proposed revising the respiratory schedule. Under the proposal, sleep apnea that is successfully treated by CPAP could be rated lower (even 0 percent), with higher evaluations reserved for cases where treatment does not work or cannot be tolerated. This is a proposal in the Federal Register, not the current rule. Until VA finalizes it, the current criteria above, including the 50 percent for a required breathing assistance device, still apply. If you already hold a rating when a rule changes, protection rules generally guard an existing evaluation from an automatic cut. You can follow open VA rulemaking comment windows, including any respiratory schedule updates, on our rule tracker.

Common gaps that affect claims

• You generally need a sleep study, not just symptoms. VA rarely grants sleep apnea on a description alone.
• The 50 percent turns on the required device, not the device type. A prescribed CPAP, BiPAP, or oral appliance all meet the criterion. The prescription and the sleep study together are the core evidence.
• Secondary to PTSD or to weight gain is one of the most common winning paths. It needs a nexus opinion, not just the diagnosis.
• The proposed rule is not final. Plan around the current 50 percent criteria, and watch the Federal Register for any change.
• Effective date follows the claim, so for a secondary claim the start date ties to when you filed or when entitlement arose, not the date of the sleep study.

When you read your rating decision, ask

• Is there a sleep study in the file confirming the diagnosis, and is it cited in the decision?
• Is the prescribed device documented, and did VA apply the 50 percent criterion to the requirement for the device, not to how well it works?
• If the claim was secondary, does the file hold a nexus opinion linking the apnea to the service connected condition?
• Was the decision made under the current criteria rather than the proposed rule, which is not final?

Related on this site

• How VA rates insomnia and sleep disorders
• Secondary service connection, explained
• Sleep apnea secondary to PTSD
• The C&P exam: what to expect and how to prepare
• Nexus letters: what makes an opinion credible