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Update for Sleep Apnea.

Follow the link to learn how to correctly file a claim for service-connected sleep apnea if you also have service-connected PTSD. You must have a nexus first.


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Preparing your claim for sleep apnea - secondary to Medication you take for PTSD and or MDD

This is a follow up on an older article. The original article is added below for your reference.


Preparing your claim

A claim for veterans disability compensation on sleep apnea, secondary to medication taken for the treatment of PTSD, should have all elements completed before you file. You may then file a “Fully Developed Claim” (FDC) with your VA Regional Office (VARO). This allows them to process your claim faster. However, if any evidence is missing, no matter what the reason, it will be left out of consideration when your FDC is reviewed to make a determation.

There are opportunities to make mistakes in preparing the claim at every step of the process. Take time to get everything done right before you file your claim. Sleep apnea is NOT a presumptive condition, meaning you, as a veteran, must meet the normal burden of proof before the VA may consider your claim as having merit. You must show that you have sleep apnea, and that is it a least as likely as not that it is service-connected.

If you are claiming sleep apnea, secondary to PTSD, you should already be rated as service connected for PTSD. If not, you must organize and word your claim carefully, so it is clear to the rating officer that she must first determine your claim for PTSD, and only then consider your sleep apnea.

Once you are service connected for PTSD, you need to show it is "as likely as not" that your sleep apnea is somehow related to your PSTD. You may do this by including copies of this 2005 article and this 2013 article, both from the journal Sleep, with your claim. You may also include this 2010 abstract from the journal Chest. The first study looked at every Veteran enrolled in the VA system and determined a strong correllation of comorbidity between PTSD (or any other anxiety/mood disorder) and sleep apnea. The second study builds on the first. It looks at active duty military personnel at Madigan Army Medical Center in Tacoma, WA, and makes a strong link between PTSD and Sleep apnea. The Chest abstract came from research done at Walter Reed Army Medical Center in Bethesda, MD. These articles make the "as likely as not" case for you. You can add additional evidence, but it is important to avoid over-complicating your claim.

Many veterans with sleep apnea and PTSD have also gained weight since leaving military service. If this is not addressed in your claim, it may create an opening for the VA rater to deny your claim. If you have gained weight, then use the information in the next section to bolster your claim, as well as your visits with your personal doctor and your examining doctor.

Many claims related to mental health, including PTSD, will be denied by raters at the VARO. The first person who rates your claim may not be well educated about this, or they may be allowing pre-conceived notions to interfere with considering the evidence and the law. If you believe you have a solid claim, but it is denied, state your disagreement and get a hearing before the Decision Review Officer (DRO) or the Board of Veterans Appeals to.  Do not give up! The VA's job is to help you, even when an individual or two within the system are not doing that.

If your claim has been denied, keep in mind when you write up your Notice of Disagreement (NOD), that you cannot use a BVA case to support your claim. They can be a good source of information, but they do not carry the weight of 'legal precedent' in the way a court case does.


Preparing for your examination by a doctor

One piece of evidence that will help your claim is having your doctor write a letter saying exactly what the journal study states: based on the science, "it appears to be as likely as not that your sleep apnea and your PTSD are related conditions". Remember, since this is a claim for a secondary condition, you are trying to prove the connection between sleep apnea and your service-connected PTSD, not the direct link sleep apnea and your military service. This letter may come from the VA examiner assigned to you after you file a claim. However, such doctors are often hesistant to write such a letter. It is in your best interest to provide this letter from your own doctor when you file the claim. That letter can even provide 'cover' for the VA doctor who examines you later, thus helping your claim twice.

The doctor's examination is critical to your claim. If the doctor who examines you believes it is at least "as likely as not" that your sleep apnea is related to your PTSD (and they will put that in writing), you have a strong claim that is likely to be granted.

Here is a checklist of things you will want to bring with you and show your doctor:

  • Studies that show the correlation between PTSD and sleep apnea in veterans.
  • A list of medications you take for service-connected conditions, highlighting any that cause weight gain among their side effects.
  • Evidence that you have gained weight since starting those medications.
  • List of any service-connected conditions or treatments which limit your physical activity.

If a rater is inclined to deny your claim for sleep apnea, they may do so by citing your weight and weight gain. They will state that they believe your weight gain is more likely to be the cause or your sleep apnea than your PTSD, and therefore your claim will be denied. To head this off, you must show that, in fact, your weight gain is also a result of service-connected conditions. Once you do this, you take away the main argument against your claim and you clear the path to get a service-connected rating for sleep apnea.

Not every VA examination doctor is experienced in areas of medical practice related to your claim. Some of them are also hesitant to do anything that may appear to 'support' your claim, regardless of their expertise. If you receive an exam which is incomplete or incorrect, you may show the VA that you had an “inadequate medical exam” and ask for a second opinion by a different doctor.  You have that right.


Get someone in your corner when you appeal

If you have already had your claim denied, it is important to have a veterans service representive, claims agent, or attorney who understands VA laws and regulations as they pertain to your specific situation, and who understands how to best refute the rating and statement of case the VA used to deny your claim. This person has your back, and can make the difference in whether your receive benefits or not. The person you choose should show you that they understand your claim, and that they can find and cite specific court cases that may help you win your appeal.


Conclusion and links to other studies

Many conditions are believed to cause or result in sleep apnea symptoms. Any nasopharyngeal (nose and throat) abnormalities that reduce the openings of the airways “can” lead to an apnea condition. Rhinitis is a common condition that can lead to sleep apnea. PTSD and depression have clear correlations with increased rates of sleep apnea. Depression and dysthmia can be the result of sleep apnea, as well, due to the lack of sleep and its impact on the mood. Heart Disease is a leading cause of Central Sleep Apnea. Strokes have been known to cause central sleep apnea as well.

There is also a mounting body of evidence that suggests a causative relationship between Traumatic Brain Injury (TBI) and many sleep disorders, including sleep apnea.

To prove secondary service-connection, the Veteran will need to prove, or service-connect, the first condition. A medical expert report or opinion may be crucial to providing the key linkage in this type of claim.

Here are links to studies related to this article:

Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort

Sleep Disorders and Associated Medical Comorbidities in Active Duty Military Personnel

A High Rate of Comorbid Insomnia and Obstructive Sleep Apnea.

Sleep disorders and associated medical comorbidities in active duty military personnel.



If you have PTSD and Sleep Apnea you can file for Sleep apnea as secondary to your PTSD.


Many gulf war veterans were told, in the early days of our understanding of Gulf War Illness (GWI), to file for PTSD instead of GWI or, as the regulation stated it, "Undiagnosed Illness (UI)". At the time, this was sound advice for some as the law from its inception until 1998 stated you had to manifest the symptoms of GWI during the gulf war or withing two year of leaving {the military/the theater}. Many doctors saw GWI as a mental health problem, and PTSD was considered the closest match for veterans who did not have evidence of symptoms within the two year window.

Of course many Gulf War veterans actually have PTSD, as do hundreds of thousands of veterans who served before and after. This article is relevant to all veterans with PTSD and sleep apnea.

Fatigue is a major component of both GWI and PTSD, but only in recent years has scientific research found insight as to why. A major study of veterans linking PTSD and sleep apnea was published in the Journal Sleep in 2005. Two later studies conducted in 2010 built on this. One was conducted at Madigan Army Medical Center in Tacoma, WA and published in the journal Sleep. The other was conducted at Walter Reed Army Medical Center in Bethesda, MD and published in the journal Chest. The Walter Reed researchers found that 73% of patients with PTSD also had sleep apnea. Their final report is here:

You may be asking, "What good is this to me?"

More veterans are getting diagnosed with sleep apnea now, but it cannot be claimed as a presumptive illness under either Undiagnosed Illness (section 3.317) or PTSD. It canot be claimed as part of Undiagnosed Illness because sleep apnea is a diagnosed illness, yet it is not among the diagnoses written into the law.

If you have PTSD and Sleep Apnea you can now file for the sleep apnea as a secondary to your PTSD. Even if you tried, unsuccessfully, to file it under the UI section you can now file for the sleep apnea again - as a secondary to PTSD. If you have an appeal going with the sleep apnea under the UI section you need to add the argument that it may also be caused by your PTSD and send in the research. In an appeal, as with an original claim, you may provide more than one argument for the same claim.

You will need to download the the related articles and make copies for yourself, your VSO, your doctors and a C&P exam. Have your VSO file the claim. In many cases your VSO will want you to get your doctor to give a nexus of the PTSD and the sleep apnea first. This will help your claim go faster. Show your doctor the two papers pointing out the highlighted parts and make sure to give a copy to your PTSD doctors too.

When you go into your C&P exam for the sleep apnea you will need to show them the research papers too. Get them to understand what it is saying. Highlight this part of the first article:

A background of hyperarousability in patients with PTSD creates instability of sleep continuity. This instability probably contributes to the development of both obstructive sleep apnea (OSA) and central sleep apnea. In a recent study of active duty servicemen, Dodson et al (Chest. 2010;138[4]:616A) found that 73% of randomly...

If your doctors put it in your records, make sure to get a copy of the C&P exam to see what is said there. If the examiner did not agree you, your VSO will need to attack the C&P ASAP. Many of the examiners are PA's and Nurse-P and are not as experienced as your doctor.




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