Secondary service connection
Sleep apnea secondary to PTSD: BVA grant rates and what wins
From 2017 to 2026, the Board of Veterans' Appeals decided sleep apnea claimed as secondary to PTSD in 11,479 decisions. It granted the issue in 31.7% of them, above the 26.4% grant rate for all sleep apnea issues, denied it in 13.5%, and remanded it in 53.8%. Counting only decisions on the merits, 70.1% were granted.
Decisions
11,479
2017–2026
Granted
31.7%
All sleep apnea: 26.4%
Granted on the merits
70.1%
Granted ÷ (granted + denied)
Remanded
53.8%
Denied: 13.5%
How VA rates sleep apnea
Once service connection is granted, VA assigns a disability rating from the rating schedule: 38 CFR 4.97, diagnostic code 6847 (Sleep Apnea Syndromes (Obstructive, Central, Mixed)). The rating is the same whether the condition is service connected directly or as secondary to another disability.
| Rating | Criteria |
|---|---|
| 100% | Chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy |
| 50% | Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine |
| 30% | Persistent day-time hypersomnolence |
| 0% | Asymptomatic but with documented sleep disorder breathing |
Text of 38 CFR 4.97 as of Feb 27, 2026. Confirm the current text at the source before relying on it.
See all sleep apnea decisions, direct and secondary.
Sleep apnea secondary to PTSD: outcomes by year
| Year | Issues decided | Granted | Denied | Remanded | Other |
|---|---|---|---|---|---|
| 2017 | 293 | 14.3% | 30.7% | 51.9% | 3.1% |
| 2018 | 660 | 22.6% | 19.2% | 55.9% | 2.3% |
| 2019 | 1,037 | 23.8% | 17.6% | 57.7% | 1.0% |
| 2020 | 1,245 | 22.7% | 18.1% | 58.2% | 1.0% |
| 2021 | 1,182 | 22.7% | 19.5% | 56.9% | 0.8% |
| 2022 | 1,181 | 22.7% | 14.6% | 62.0% | 0.8% |
| 2023 | 1,449 | 31.7% | 10.6% | 56.8% | 1.0% |
| 2024 | 1,938 | 41.5% | 8.0% | 49.5% | 0.9% |
| 2025 | 1,816 | 43.6% | 8.4% | 47.2% | 0.8% |
| 2026 | 689 | 47.8% | 9.3% | 41.7% | 1.3% |
Each row counts issues (each condition the Board decided), so the shares add up to 100%. Other: dismissed, withdrawn or no clear outcome. Years with fewer than 20 issues are left out.
Evidence in granted and denied sleep apnea decisions
For each kind of supporting evidence: how often the Board granted the sleep apnea issue on the merits when the decision mentioned it, compared with decisions that did not. These are associations, not causes, and evidence is recorded per decision, not per issue.
| In the record | Decisions | Granted when present | When absent | Difference |
|---|---|---|---|---|
| Positive nexus opinion | 3,841 | 93.5% | 34.5% | +59.0 pts |
| Private medical opinion | 5,202 | 84.1% | 41.2% | +43.0 pts |
| Favorable VA exam | 1,182 | 84.3% | 67.5% | +16.9 pts |
| Treating physician opinion | 644 | 75.4% | 69.7% | +5.8 pts |
| Buddy statement | 805 | 74.7% | 69.8% | +4.9 pts |
| Combat service | 1,206 | 70.3% | 70.1% | +0.2 pts |
| Lay statement | 8,132 | 62.5% | 91.2% | −28.7 pts |
- The Board applied the benefit-of-the-doubt rule (38 CFR 3.102) in 77.6% of the decisions that granted sleep apnea.
- The Board found the veteran's statements credible in 21.2% of grants and 10.9% of denials.
Negative evidence in the record
An unfavorable exam or a negative nexus opinion often sits in the same record as favorable evidence, and the Board weighs them against each other. So these rows show how often sleep apnea was still granted when the record contained the negative item, not that the item helped.
| In the record | Decisions | Granted when present | When absent | Difference |
|---|---|---|---|---|
| Negative nexus opinion | 8,226 | 67.6% | 78.6% | −10.9 pts |
| Unfavorable VA exam | 9,475 | 68.0% | 85.2% | −17.2 pts |
How these claims are argued
A secondary claim says PTSD caused sleep apnea or made it worse, and names how. Below: whether the Board's decision discussed aggravation, and the medical link each decision names, with how often those issues were granted.
Aggravation discussed
made worse by the disability, 3.310(b)
23.9%
granted, of 5,516 issues (48.0% of all)
Causation only
caused by the disability, 3.310(a)
38.8%
granted, of 5,974 issues (52.0% of all)
| Medical link named | Issues | Granted |
|---|---|---|
Weight gain or obesity Granted “Opinion not probative as it failed to consider evidence linking binge eating/night eating to obesity” 26000195 (2026) Denied “Examiners cited lack of nexus and alternative causes (obesity, age) for OSA.” 26000852 (2026) | 2,910 | 34.2% |
Sleep disruption Granted “Earlier VA opinions found PTSD causes chronic sleep impairment.” 26000166 (2026) Denied “Veteran denied sleep problems in service.” A26000039 (2026) | 1,080 | 28.9% |
Stress Granted “The Board relied on a private medical opinion that linked OSA to PTSD symptoms, stress, hyperarousal, and indirectly to obesity, outweighing a VA opinion that disassociated OSA from herbicide exposure.” A26001491 (2026) Denied “The veteran claimed OSA was due to service, specifically citing stress during Hurricane Katrina, service in Iraq, and as secondary to his service-connected PTSD.” A24064685 (2024) | 133 | 53.4% |
Medication side effects Granted “Service connection is granted on a secondary basis because the Board found the Veteran's service-connected acquired psychiatric disorder (PTSD with secondary alcohol use disorder, cocaine use disorder, opioid use disorder) caused or...” A26005231 (2026) Denied “Private opinions flawed due to misidentification of medication side effects and timing of weight gain.” A24079117 (2024) | 87 | 43.7% |
Nerve involvement Granted “concluded PTSD, strain, radiculopathy led to obesity, contributing to OSA.” A25005012 (2025) Denied “The Veteran claims OSA is secondary to service-connected PTSD, diabetes mellitus II, and bilateral sciatic nerve peripheral neuropathy associated with DMII.” 25008510 (2025) | 82 | 41.5% |
Reduced activity or mobility Granted “Opinion noted Veteran's obesity, chronic pain, limited mobility, and PTSD medication causing weight gain.” A26001655 (2026) Denied “The Veteran asserted that PTSD led to emotional eating and weight gain, while the back disability limited mobility and exercise, both contributing to sleep apnea.” A24048650 (2024) | 65 | 64.6% |
Chronic pain Granted “Opinion noted Veteran's obesity, chronic pain, limited mobility, and PTSD medication causing weight gain.” A26001655 (2026) | 50 | 58.0% |
Altered gait or overuse Granted “The Board found the evidence persuasively favored the Veteran, granting service connection based on a credible private medical opinion that linked OSA to PTSD and its treatment, despite negative VA opinions.” A25045848 (2025) Denied “Symptoms of OSA (daytime sleepiness) are already compensated by the 70 percent rating for PTSD..” A25033889 (2025) | 38 | 39.5% |
Based on words in the AI-written summary and reasons for each issue, not a reading of the full decision. 34.4% of the 11,490 issues name at least one medical link; the rest only say “secondary to” the disability. One issue can name several links. Granted is the share of those issues granted (remands count as not granted). A link named in a denial was often the argument the Board rejected.
Why the Board granted or denied sleep apnea
Most common reasons in grants
- Current diagnosis established481
- Service connection established331
- Caused by the service-connected disability189
- Aggravated by the service-connected disability117
- VA examiner: less likely than not related to service115
- Service records negative or silent32
- Secondary to PTSD23
- Criteria for secondary service connection met23
Most common reasons in denials
- VA examiner: less likely than not related to service395
- No in-service complaints, treatment or diagnosis277
- Service records negative or silent207
- Preponderance of the evidence against the claim174
- No current diagnosis68
- Current diagnosis established54
- Aggravated by the service-connected disability31
- Caused by the service-connected disability14
Numbers are decisions that gave the reason. Reasons are short phrases extracted by AI from each decision; common wordings of the same reason are grouped. Benefit of the doubt is reported above.
Recent sleep apnea decisions
Granted
Private medical opinion from treating provider found more probative; Opinion linked sleep apnea to PTSD based on medical literature and Veteran's history; Resolved doubt in Veteran's favor
Current diagnosis of sleep apnea established.; Private physician opinion found at least as likely as not that sleep apnea was directly attributable to long-term consequences of service-connected PTSD and related conditions.; No contrary medical opinion of record.
Current disability (OSA) demonstrated; Service connection for PTSD with persistent depressive disorder and insomnia established; Private medical opinion linked OSA to PTSD based on literature and PTSD symptomology; Private opinion found OSA at least as likely as not due to PTSD; No conflicting medical opinion in record
Denied
Weight of evidence against service connection; VA examiner found sleep apnea less likely than not related to PTSD; Sleep apnea multifactorial, not directly caused by PTSD
No evidence of sleep apnea during service or continuous symptoms; VA examiner opined less likely related to service, more likely due to obesity; Private opinions lacked probative value as they did not apply research to veteran's circumstances
Granted service connection at 50% as secondary to PTSD; Did not meet criteria for rating higher than 50%; Condition required CPAP machine without complications
What VA needs to grant a secondary claim
Secondary service connection means VA disability benefits for a condition caused or made worse by a disability that is already service connected (38 CFR 3.310). The claim needs three things:
- A current diagnosis of sleep apnea.
- PTSD is already service connected.
- Medical evidence linking them (a nexus opinion): sleep apnea was caused by PTSD (3.310(a)), or was made worse beyond its natural progress by it (aggravation, 3.310(b)).
VA's procedures for these claims are in M21-1 V.ii.2.D. When the evidence for and against is about even, VA must decide in the veteran's favor (38 CFR 3.102).
Other conditions secondary to PTSD
- Major depressive disorder secondary to PTSD305 decisions · 62.0% granted
- Migraine secondary to PTSD1,732 decisions · 37.1% granted
- Erectile dysfunction secondary to PTSD1,645 decisions · 30.3% granted
- Gastroesophageal reflux disease (GERD) secondary to PTSD1,237 decisions · 25.3% granted
- Irritable colon syndrome (spastic colitis mucous colitis) secondary to PTSD380 decisions · 24.2% granted
- Diabetes mellitus secondary to PTSD551 decisions · 20.3% granted
- Hypertension secondary to PTSD3,194 decisions · 16.5% granted
Sleep apnea secondary to other conditions
- Sleep apnea secondary to a knee condition983 decisions · 46.2% granted
- Sleep apnea secondary to a back condition1,166 decisions · 38.2% granted
- Sleep apnea secondary to a psychiatric disorder4,474 decisions · 33.1% granted
- Sleep apnea secondary to diabetes994 decisions · 23.0% granted
- Sleep apnea secondary to tinnitus632 decisions · 20.7% granted
- Sleep apnea secondary to hypertension692 decisions · 14.6% granted
See all conditions secondary to PTSD or sleep apnea as a primary or secondary condition.
Rules that apply to secondary sleep apnea claims
- 38 CFR 3.310
Secondary service connection and aggravation
Read it in VA Law Explorer - M21-1 V.ii.2.D
Secondary service connection and aggravation of non-service-connected disabilities
Read it in VA Law Explorer - 38 CFR 3.102
Reasonable doubt (benefit of the doubt)
Read it in VA Law Explorer - 38 CFR 4.97 · DC 6847
Schedule of ratings: respiratory system
Read it in VA Law Explorer - M21-1 IV.i.3.B.1.l
Reviewing a sleep disorders examination
Read it in VA Law Explorer
Research your sleep apnea case
Narrow by year, judge, evidence or secondary condition, read the decisions, and export a research memo.
How these numbers are calculated
- Counts decisions in which the Board decided a sleep apnea issue claimed as secondary to PTSD, by the outcome of that issue.
- The primary disability is read from the decision text ("secondary to …") and grouped by name, so spellings such as "PTSD" and "posttraumatic stress disorder" count together.
- Secondary claims also include aggravation of a non-service-connected condition by a service-connected one (38 CFR 3.310(b)).
- The data comes from CaseScribe's AI extraction of public BVA decisions (2017–2026) and can contain errors. It is updated automatically as new decisions are added.