SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran, who served from November 1984 to August 1991, appeals the denial of a compensable rating for obstructive sleep apnea (OSA). The veteran was diagnosed with OSA in February 2005, after the onset of service-connected PTSD, and has used a CPAP machine since diagnosis. The Board reviewed the evidence, including private physician opinions and multiple VA examinations, to determine the nexus between OSA and PTSD and the appropriate disability rating. While a private physician opined OSA was more likely than not secondary to PTSD, a December 2020 VA examiner found OSA and PTSD to be separate and unrelated, citing studies suggesting PTSD is not a recognized cause of OSA. A September 2021 VA examiner found OSA less likely than not proximately due to PTSD but also found it at least as likely as not aggravated by PTSD, noting PTSD can worsen sleep symptoms. A May 2022 VA examiner noted current OSA symptoms including hypersomnolence and associated OSA with PTSD, citing literature on increased prevalence of OSA in veterans with PTSD. The Board found that the veteran's OSA, requiring CPAP use, met the criteria for a 50 percent rating. Applying the benefit of the doubt due to an inability to determine a precise pre-aggravation baseline severity, the Board assigned a 0 percent pre-aggravation rating. Subtracting the baseline from the current 50 percent rating resulted in a 50 percent rating for OSA, but no higher, as the veteran did not demonstrate chronic respiratory failure, cor pulmonale, or tracheostomy. The Board granted a 50 percent rating for OSA.

Rationale

Current severity of OSA meets criteria for 50% rating due to CPAP use.; Benefit of the doubt applied due to inability to determine precise pre-aggravation baseline severity.; Pre-aggravation baseline rating determined to be 0%.

Full Decision Text

Citation Nr: A26039818
Decision Date: 04/28/26	Archive Date: 04/28/26

DOCKET NO. 230331-335593
DATE: April 28, 2026

ORDER

A rating of 50 percent, but no more, for obstructive sleep apnea (OSA) is granted, subject to the payment of monetary benefits.

FINDINGS OF FACT

1. The Veteran served on active duty from November 1984 to August 1991; he has been 100 percent disabled since August 2022, plus in receipt of special monthly compensation (SMC). 

2. OSA, diagnosed after onset of service-connected posttraumatic stress disorder (PTSD), has required the use of a continuous airway pressure (CPAP) machine since it was first diagnosed; chronic respiratory failure with carbon dioxide retention or cor pulmonale, or a required tracheostomy have not been shown. 

CONCLUSION OF LAW

The criteria for a 50 percent rating, but no more, for OSA have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.31, 4.97, Diagnostic Code (DC) 6847 (2025).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

This decision has been written under the guidelines of the Veterans Appeals Improvement and Modernization Act, also known as the Appeals Modernization Act (AMA). In October 2022, the agency of original jurisdiction (AOJ) denied the claim. In March 2023, the Veteran appealed to the Board via a Form 10182 and elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ decision on appeal. 38 C.F.R. § 20.301. 

In January 2025, the Board denied the claim for a compensable rating for OSA. The Veteran appealed to the Veterans Claims Court. In December 2025, the Court Clerk granted a joint motion for remand (JMR) and remanded the claim to the Board for readjudication.

Turning to the relevant laws and regulations, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1.  Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4.

Importantly, in cases of aggravation, assigned ratings reflect the degree of disability over and above the pre-existing degree of disability. Therefore, when service connection based on aggravation is granted, VA must first determine the overall level of disability and then subtract from that the level of disability which existed prior to aggravation. 38 C.F.R. § 3.310.

The difference between the two represents the percent disability for the condition. If, however, the aggravated disability is found to be totally disabling, no reduction takes place. Similarly, if the degree of pre-existing disability cannot be determined, no reduction takes place.

Here, the Veteran's service-connected OSA has been assigned a noncompensable rating under DC 6847, effective from April 15, 2015. Specifically, the AOJ granted service connection for OSA in a September 2021 rating decision on the basis that OSA was permanently aggravated/worsened as a result of service-connected PTSD. 

Pursuant to DC 6847, a noncompensable rating contemplates asymptomatic sleep apnea, but with documented sleep disorder breathing. A higher evaluation of 30 percent may be assigned for persistent daytime hypersomnolence. A 50 percent rating is assigned when the sleep apnea requires the use of a breathing assistance device such as CPAP machine. A maximum 100 percent rating is assigned for sleep apnea that causes chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires tracheostomy.

As noted above, the AOJ granted service connection for OSA in a September 2021 rating decision. The AOJ determined the baseline pre-aggravation evaluation to be 50 percent based on the Veteran's use of a CPAP machine.

Further, the AOJ found the current severity of the OSA to warrant a 50 percent rating based on use of a CPAP machine. Therefore, the 50 percent rating for current severity was subtracted from the 50 percent pre-aggravation rating, resulting in a noncompensable rating for
 CPAP machine. A maximum 100 percent rating is assigned for sleep apnea that causes chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires tracheostomy.

As noted above, the AOJ granted service connection for OSA in a September 2021 rating decision. The AOJ determined the baseline pre-aggravation evaluation to be 50 percent based on the Veteran's use of a CPAP machine.

Further, the AOJ found the current severity of the OSA to warrant a 50 percent rating based on use of a CPAP machine. Therefore, the 50 percent rating for current severity was subtracted from the 50 percent pre-aggravation rating, resulting in a noncompensable rating for the obstructive sleep apnea.

The medical evidence reflects that the Veteran was first diagnosed with mild to moderate OSA in February 2005 following a sleep study. He was prescribed treatment by CPAP machine to manage symptoms. An August 2011 clinical treatment notes reflected impaired sleep and trouble staying asleep due to sweating and shaking at night. Further, in March 2015, a clinician noted continued use of CPAP. 

In April 2015, a private physician opined that OSA was more likely than not secondary to PTSD. Citing to medical studies, he explained that PTSD often resulted in increased incidence of sleep disturbances. The clinician also noted that the Veteran was still prescribed the use of CPAP. In September 2019, a private sleep study concluded that OSA was of "mild" degree of severity. 

Next, a December 2020 VA examiner noted a current diagnosis of OSA with symptoms of fatigue. The examiner specifically did not mark the box on the examination report for "persistent daytime hypersomnolence," "carbon dioxide retention," "chronic respiratory failure,, "cor pulmonale," or "requires tracheostomy" which indicates that none of those symptoms were present. 

Further, the December 2020 VA examiner found that while OSA and PTSD may have co-existed, they were separate and unrelated entities. He cited to a medical study which found that PTSD was not a recognized cause of OSA. As such, he found it less likely than not that OSA was proximately due to service-connected PTSD. 

In September 2021, a VA examiner found it less likely than not that OSA was proximately due to or the result of PTSD. He noted that there was no definitive medical evidence that PTSD and OSA shared a medical nexus. However, the same examiner also found that OSA was at least as likely as not aggravated beyond its natural progression by service-connected PTSD. He explained that medical research indicated that PTSD interfered with the ability to fall asleep and did not allow for the effective use of a CPAP machine. Further, the September 2021 VA examiner indicated that a baseline level of severity of OSA could not be determined. 

In May 2022, a VA examiner noted that current symptoms of OSA included persistent daytime hypersomnolence. He found no evidence of carbon dioxide retention, chronic respiratory failure, cor pulmonale, or the need for a tracheostomy. Further, he noted that that current OSA was associated with PTSD. He cited to medical literature which showed an increased prevalence of PTSD amongst veterans with recurrent nightmares and disrupted sleep. In addition, he noted that veterans with PTSD have a high prevalence of OSA, which could worsen the sleep related symptoms of PTSD. 

After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that a 50 percent rating, but no higher, is warranted for the OSA aggravated by PTSD.

In adjudicating the increased rating issue on appeal, the Board will compare the current level of severity of OSA to the baseline level of severity, in order to adequately address the degree of aggravation that is currently service-connected and compensable. See 38 C.F.R. § 3.310(b).

With regard to the current level of severity of OSA, the medical evidence of record demonstrates that OSA requires use of a CPAP machine. Thus, this current level of severity meets the criteria for a 50 percent rating.

With regard to the baseline level of severity for OSA, the clinical treatment records confirm diagnosis and treatment of PTSD dating back to October 2004, prior to the diagnosis of OSA in February 2005. Specifically, the Veteran underwent a sleep study and was diagnosed with OSA in February 2005 and was prescribed treatment by CPAP. Further, there is no indication of diagnosis of OSA, or sleep disordered breathing, day-time hypersomnolence, or use of a CPAP prior to February 2005. The September 2021 VA examiner was also unable to determine a baseline level of severity of sleep apnea. 

Therefore
 Thus, this current level of severity meets the criteria for a 50 percent rating.

With regard to the baseline level of severity for OSA, the clinical treatment records confirm diagnosis and treatment of PTSD dating back to October 2004, prior to the diagnosis of OSA in February 2005. Specifically, the Veteran underwent a sleep study and was diagnosed with OSA in February 2005 and was prescribed treatment by CPAP. Further, there is no indication of diagnosis of OSA, or sleep disordered breathing, day-time hypersomnolence, or use of a CPAP prior to February 2005. The September 2021 VA examiner was also unable to determine a baseline level of severity of sleep apnea. 

Therefore, giving the Veteran the benefit of the doubt, and in the absence of evidence of persistent daytime hypersomnolence and medical evidence requiring use of a CPAP machine prior to the onset of aggravation by the Veteran's service-connected PTSD, the Board finds that the pre-aggravation level is noncompensable.

Therefore, pursuant to 38 C.F.R. § 3.310(b), the baseline pre-aggravation disability level (0 percent) is deducted from the post-aggravation disability level (50 percent), resulting in disability rating of 50 percent, but no higher, for OSA.

However, a rating in excess of 50 percent is also not warranted. The evidence fails to demonstrate that the Veteran has chronic respiratory failure with carbon dioxide retention or cor pulmonale, nor is there indication of tracheostomy. Accordingly, there is no basis upon which to assign the maximum 100 percent rating for OSA at any time during the appeal period. 

In granting a higher rating, the Board has considered the Veteran's lay statements regarding his symptoms as well as the evidence provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. In sum, after a careful review of the evidence of record, a 50 percent rating, but no more, for OSA is granted.

Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 

 

 

L. HOWELL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Kokolas, Thomas

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.