Top 5 Reasons for Obstructive Sleep Apnea Claim Denials

Top 5 Reasons for Obstructive Sleep Apnea Claim Denials (Plus OSA Service Connection Tips)

Was your obstructive sleep apnea (OSA) VA claim denied? OSA is a common denial veterans receive when pursuing a VA claim, but it doesn’t have to be—if you understand the condition and what your claim must include in order to be successful.

In this article, we’ll help you understand the top 5 reasons OSA claims are denied—and even better, what to do about it if you’ve received a denial for your OSA claim. We share our top tips and a step-by-step guide to a successful claim for obstructive sleep apnea!

What is obstructive sleep apnea?

First of all, let’s explore a little about this common disability in veterans, so you understand the condition and why it’s important you pursue your claim and get the benefits you deserve.

Sleep apnea is a sleep disorder in which breathing is repeatedly interrupted during the course of sleep. Broadly, it’s defined as the occurrence of five or more breathing-related “events” per hour, measured by polysomnography (sleep study).

These temporary breathing disruptions or lapses can occur from dozens to hundreds of times per night. The resulting reduction in sleep quality and in the body’s supply of oxygen can have serious consequences on health and quality of life.

Obstructive sleep apnea (OSA) is the most common type of sleep apnea. It occurs when airflow is impaired repeatedly during sleep due to blockage in the upper airway. The blockage is believed to occur when the muscles in the back of the throat become overly relaxed.

Some of the most common symptoms of sleep apnea include:

• Disrupted breathing in which a person’s respiration can become labored or even stop for up to a minute at a time
• Excessive daytime sleepiness
• Morning headaches
• Irritability
• Limited attention span or difficulty thinking clearly
• Snoring, including snoring that is especially loud and involves gasping, choking, or snorting that may cause a person to briefly wake up
• Morning sore throat or dry mouth

People who suffer from sleep apnea are often unaware of the breathing disturbances, finding out about them from a bed partner or roommate. Excessive daytime sleepiness is the most noticeable signal for those who live alone.

Left untreated, sleep apnea can lead to cardiovascular diseases (high blood pressure, heart failure, arrhythmias, stroke), diabetes, depression, and headaches, among others.

Obstructive sleep apnea is estimated to affect between 2-9% of adults (about 15 million Americans) but is believed to be frequently undiagnosed.

Sleep apnea is extremely common among veterans, as the disorder is frequently caused or exacerbated by time in service. (In one study, 69.2% of veterans were assessed as being at high risk for OSA.)

If you’re experiencing any of the symptoms listed above, and suspect your sleep apnea arose from your time on active duty (or was or aggravated by a currently service-connected disability), you should consider seeking a diagnosis and pursuing compensation for this disability.

Even if you’ve been denied before, it’s not too late!

The Top 5 Reasons OSA Claims Are Denied

VA claim for sleep apnea denied? In our experience, OSA denials are almost always due to one or more of these five gaps:

• #1. No current sleep study within the last 12 months
• #2. No current medical diagnosis (within the last 12 months), or improper diagnosis
• #3. No proof of service connection (missing  a nexus letter)
• #4  Lack of active-duty documentation and medical evidence
• #5  Filing for direct service connection vs secondary service-connection (secondary to an already service-connected disability)

Fortunately, there are simple strategies you can employ to address these factors—even if the VA has already denied your VA claim for sleep apnea.

Steps and Strategies: How to Prove Service Connection for Sleep Apnea 

Follow the steps below to remedy the above-listed typical reasons for denial, and you’ll be much closer to a winning claim!

• Step #1: Get a NEW sleep study (if yours was not in the last 12 months)
• Step #2: Confirm a medical diagnosis of sleep apnea with a sleep specialist (or your primary care provider)

• Step #3: Obtain a nexus letter for sleep apnea
• Step #4: Pursue filing for OSA or SA as secondary to an already service-connected disability (if a diagnosis of OSA or SA was not documented in your service treatment records while on active duty)

Step #1: Get a NEW Sleep Study (within the past 12 months)

If you have symptoms of OSA, consider obtaining a sleep study, also known as polysomnography.

Even if you’ve had a sleep study before, it’s important to get one done within the 12 months prior to your VA claim. This will confirm a medical diagnosis and current symptoms, especially if they’ve become more severe over time.

A sleep study is critical to confirming whether you meet the clinical diagnostic criteria for sleep apnea.

The polysomnography study records your brain waves, the oxygen levels in your blood, your heart rate and breathing, and eye and leg movements, among other criteria.

There are three primary ways for veterans to get a sleep study:

1. Discuss your sleep issues with your primary care VA doctor and ask for a referral to a sleep specialist at the VA.
2. Ask your private doctor for a referral to a sleep specialist in your area (a good option if you have private health insurance).
3. Order a sleep apnea at-home test kit.

Step #2: Obtain a medical diagnosis of sleep apnea from a sleep specialist

Once you’ve finished your sleep study, it’s important to review your results with a sleep specialist to confirm whether you have a medical diagnosis of sleep apnea.

You only need to establish that your sleep apnea is “at least as likely as not”:

• caused or made worse by your active duty military service OR
• aggravated beyond its natural progression by another service-connected condition (for secondary service connection).

Step #3: Get a nexus letter for sleep apnea from a credible independent medical professional 

A nexus letter is an evidence-based document prepared by a medical professional that helps to establish a connection between the veteran’s current disability and either military service (for direct service connection) or another rated disability (for secondary service connection).

A nexus letter is often the missing link in a VA claim. It’s an essential piece of evidence. In our experience, most VA disability claims are won or lost based on medical evidence.

Lack of Medical Evidence is the #1 Reason VA Claims are Denied

Therefore, a well-crafted nexus letter for sleep apnea is the single most crucial document a veteran can provide the VA adjudicator to help prove service connection on an “at least as likely as not” basis.

A credible nexus letter fulfills one of the requirements for secondary service connection for sleep apnea: medical nexus evidence establishing a connection between the service-connected disability and the current disability (sleep apnea).

The independent opinion of a private medical professional can also influence the C&P examiner’s medical opinion, as well as the VA rating official’s final disability decision.

See our tips on how to obtain a credible nexus letter.

Step #4: Consider secondary service connection instead of direct service connection

You’ll need to make the call on direct service connection versus secondary service connection.

In our opinion, the only time a veteran should pursue direct service connection for sleep apnea is if you had a sleep study performed while on active duty, which confirmed the presence of a sleep apnea condition (medically diagnosed) during active-duty service.

Direct Service Connection Requirements

There are three components to proving direct service connection for any VA disability claim:

• A current disability (medical diagnosis in medical records)
• An in-service event, injury, disease, or aggravation; and
• A link or nexus establishing that the current disability had its onset, inception, or aggaravation in service, which may be established by
  • evidence of chronicity and continuity in your service treatment records and private treatment records, or
  • a medical nexus opinion.

For the legal principles of direct service connection, see 38 CFR 3.303.  Also see our post What is a Service-Connected Disability?

Secondary Service Connection Requirements

In our experience, if you did NOT have a sleep study while on active duty and you did not get a medical diagnosis of sleep apnea in the military, you should only attempt to service-connect your sleep apnea VA claim SECONDARY to another service-connected disability.

Service connection on a secondary basis requires evidence of aggravation or causation.This requires that the secondary disability be shown to be “proximately due to” or “proximately aggravated by” another service-connected disability.

By law, there are three evidentiary elements that must be satisfied for sleep apnea secondary conditions to prove secondary service connection:

1. A medical diagnosis of sleep apnea confirmed by a sleep study in VA medical records or private records (sleep study in past 12 months)
2. Evidence of a service-connected primary disability (such as PTSD, depression, anxiety, sinusitis, rhinitis), AND
3. Medical nexus evidence establishing a connection between the service-connected disability and the current disability

The first part can be satisfied with any existing medical evidence— service treatment records, VA medical records, or any private medical records, assuming you do have a diagnosis of sleep apnea.

The second part can be satisfied with your existing service-connected disability rated at 0 percent or higher.

The third part can be satisfied with a nexus Letter from a qualified medical professional, as noted above.

Which primary disabilities make the best claims for secondary service connection of sleep apnea?

OSA and Upper Respiratory Conditions

In our experience, an upper respiratory disability is one of the easiest choices for claiming OSA secondary to another service-connected disability.

Both sinusitis and rhinitis are linked to sleep apnea. If you have sleep apnea and sinusitis/rhinitis, your next step would be to get a doctor’s medical opinion supporting that your service-connected sinusitis/rhinitis caused or aggravates your sleep apnea.

This may be even easier for you now because of a new VA new rule as of August 2, 2021. Thanks to additions to the VA presumptive list, you may be able to presumptively service-connect rhinitis, sinusitis, rhinosinusitis or asthma if you served in particular theaters during specified time periods. This opens doors for many veterans who were unable to service-connect these respiratory conditions previously. See our article Burn Pit Presumptive Conditions.

OSA and PTSD

OSA secondary to PTSD (or other mental health claim) is a more challenging claim to make, but it is still a top candidate for secondary service connection of sleep apnea. This is because the fact is that many veterans suffer from PTSD—and sleep problems are a common symptom of PTSD.

Emerging research indicates a strong association between PTSD and sleep apnea.The link between sleep apnea and PTSD is likely due to the fact that many factors that aggravate PTSD also aggravate sleep apnea—including sleep deprivation, insomnia, hyperarousal, and daytime sleepiness.

In a study of veterans, PTSD symptom severity increased the risk of screening positive for OSA.

Both anxiety and depression can also be linked to sleep apnea. Anxiety and depression can interfere with sleep patterns. People with sleep apnea are four times more likely to have depression than people without a sleeping disorder.

While an OSA disability claim secondary to sinusitis/rhinitis is an easier path, veterans who are service-connected for PTSD (or other mental health conditions) are eligible for secondary service connection for their sleep apnea, and it’s possible to achieve an OSA disability claim secondary to PTSD with the right strategy and credible medical evidence.

Need more help?

You can also check out our 2022 Facebook live video on the Top 5 Causes for OSA Denials and How to Fix Them!

For all about getting a VA rating for sleep apnea, see our post Your Sleep Apnea VA Rating — A Guide to Getting a VA Disability Rating for Sleep Apnea.

As you’ve seen, claims for obstructive sleep apnea can be tricky—yet important to pursue if you’re suffering from this disability, so you can get the benefits you deserve and care you need. We can help—reach out so we can show you how.

Get the compensation you deserve.

Regardless of whether you are dealing with OSA, it’s important to pursue all the benefits available to you as a veteran. Most veterans are underrated for their disabilities and therefore not getting the compensation they’re due.

At VA Claims Insider, we help you understand and take control of the claims process, so you can get the rating and compensation you’re owed by law.

Our process takes the guesswork out of filing a VA disability claim and supports you every step of the way in building a fully-developed claim (FDC)—so you can increase your rating faster!

If you’ve filed your VA disability claim and have been denied or have received a low rating—or you’re unsure how to get started—reach out to us! Take advantage of a FREE VA Claim Discovery Call. Learn what you’ve been missing—so you can FINALLY get the disability rating and compensation you deserve!

We’ve supported more than 15,000 veterans to win their claims and increase their ratings. NOW IT’S YOUR TURN.

About the Author

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Brian Reese

Brian Reese is one of the top VA disability benefits experts in the world and bestselling author of You Deserve It: The Definitive Guide to Getting the Veteran Benefits You’ve Earned (Second Edition).

Brian’s frustration with the VA claim process led him to create VA Claims Insider, which provides disabled veterans with tips, strategies, and lessons learned to win their VA disability compensation claim, faster, even if they’ve already filed, been denied, gave up, or don’t know where to start. 

As the founder of VA Claims Insider and CEO of Military Disability Made Easy, he has helped serve more than 10 million military members and veterans since 2013 through free online educational resources.

He is a former active duty Air Force officer with extensive experience leading hundreds of individuals and multi-functional teams in challenging international environments, including a combat tour to Afghanistan in 2011 supporting Operation ENDURING FREEDOM.

Brian is a Distinguished Graduate of Management from the United States Air Force Academy, Colorado Springs, CO, and he holds an MBA from Oklahoma State University’s Spears School of Business, Stillwater, OK, where he was a National Honor Scholar (Top 1% of Graduate School class).