The NEXUS Letter

VA Nexus Letter An Explaination And Example
An Explanation and Example

To win an award of a disability benefit, you must meet 3 criteria:

  1. You have to show eligibility of your military service.
  2. You must have a current medical diagnosis of a condition or a disability.
  3. You must be able to provide evidence that the medically diagnosed condition had its origin during the time of your military service, or if the condition was preexisting, that it was aggravated by your military service.

NOTE: A nexus letter, also known as a medical opinion will help establish your injury or illness resulted during a time of active duty. This DOES NOT establish your current level of disability. That is done with an OPTIONAL Disability Benefits Questionnaire. With Disability Benefits Questionnaires (DBQs) Veterans now have more control over the disability claims process. Veterans have the option of visiting a private health care provider instead of a VA facility to complete their disability evaluation form. Veterans can have their providers fill out any of the more than 70 DBQs that are appropriate for their conditions and submit them to the VBA. It's that easy! Here is the list on online DBQs you can take to your doctor.  Link to Over 70 DBQs


In many cases, the connection of an event that happened while you were on active duty to a diagnosed condition today may be tenuous at best.

Just because you were seen in the military for pain (e.g., knee pain, back pain, shoulder pain) or because you injured some body part (e.g., twisted ankle or knee), doesn’t mean your current ailments are related to those service events.

In this example let's consider a knee injury.

For example, while on active duty you injured your knee in 1995 while running. You returned to full duty after being on light duty for a couple of days and treated with mild pain killers and NSAIDs. You were discharged in 1997. After discharge, you worked in construction until 2008 when you lost your job due to the economy. You started working as a truck driver. In 2015 you started having knee pain in the same knee you twisted in 1995. Your return to duty after the injury, lack of major medical treatment (e.g., no surgery) in 1995, your post-military occupation, and the significant timeframe between documented symptoms would suggest no link between the two.

In another example, let's consider a back injury.

You may have hurt your back in some fashion while serving your country. That was in 1970 and you went on sick call. Your sore back was diagnosed as a "pulled muscle" or something similar and you were given some Ibuprofen and sent on your way to light duty for 3 days.

The back was progressively more painful so you were back on sick call a week later. This time an x-ray was ordered and you were given some stronger pain pills and your light-duty was increased to a restricted duty for a month with orders of no lifting, no PT and so on.

The military culture demands that we don't complain of our "minor" aches and pains. The team depends on each member being ready to complete the mission and the mission is all that counts. From day one we're trained that complaints of pain will bring about scorn from superiors and fellow soldiers will know that they have to carry your load as well as their own.

Your civilian career wasn't as physical as the military and during the years since your discharge you've had chronic, low back pain but it hasn't required much treatment...until now. In the last year, you've had to seek more intensive medical care and finally, you had an MRI. The MRI study shows numerous issues with discs and nerves and you realize that your old service injury is here to haunt you.

You file for service-connected disability compensation, you have a C & P exam and about a year later you have a denial letter. The VA tells you that although you had complaints during your service that your condition today is new and unrelated to those old problems.

In order to service connect the knee, you will need a well-written nexus letter clearly outlining why your current diagnosis is related to the in-service event. That nexus letter should explain why other etiologies and/or your life experiences since discharge are not the cause of your current diagnosis.

Now what?

The nexus letter is the key to overturning the denial. Nexus is defined as "the means of connection between things linked in series."

The task you face now is to seek an expert physician who will review your complete medical records and write a letter stating that it it his or her opinion that your injury (condition) today is related to the military service.

The nexus letter should follow a similar format to all letters that you use to communicate to the VA. It may be addressed directly to you or in a "To Whom It May Concern" style. If the physician is willing to provide you with a current curriculum vitae (a resume) that will support the physician's expertise.

The nexus letter should follow the standard business format we always use when writing to the VA. This template below may be used as a beginning for your letter.

______________________________________________________________

Doctor's Letter Head

Date:

Subject: Medical history of Mr. Veteran

Reference: C-File # and/or Social Security Number

To the Department of Veterans Affairs:

I am the primary care provider for Mr. Veteran. In my capacity as a primary care provider, I have cared for Mr. Veteran since 01/07/20xx.

While I've provided care for Mr. Veteran, I've become familiar with his active duty medical history from 07/24/19xx to 08/07/19xx and from VA medical records from 19xx to present, past and present ailments and I've reviewed pertinent parts of his military record that document his injury, disease and clinical conditions related to the events that occurred.

I am aware that Mr. Veteran was injured during his active duty military service on or about 1981 in Fort Army while (events description, time and place).

A primary condition the veteran suffers is Lumbar Paravertebral Myositis (an Inflammatory Myopathy) and an L4-L5, disc desiccation and disc narrowing. MRI reports note sacralization of the L 5 representing a developmental abnormality and also that paraspinal muscle spasm is suggested.

Further noted are mild thoracolumbar dextroscoliosis as well as mild spondylosis and degenerative endplate changes. Schmorl's nodes in the superior endplate of L3. L3-L4 and L4-5 degenerative disc disease are seen. There is an L4-5 small posterior disc bulge and small posterior central disc herniation and L2-3 vertebral hemangiomas.

Mr. Veteran has chronic pain due to his injuries. The veteran suffers radiculopathy with pain, muscle control difficulty, tingling, numbness and weakness in the legs, likely due the sacralization of L4-L5.

Mr. Veteran suffers increased fatigability because of his chronic back pain. Standing for more than 15 minutes will make him become weak and exhausted.

There are multiple other clinical conditions diagnosed that are more likely than not secondary to or aggravated by the primary back condition(s).

The veteran takes numerous medications for both the primary condition as well as secondary conditions that are aggravated by said primary back condition. (Medicines and secondary conditions are listed separately.)

The veteran is not a likely candidate to be rehabilitated.

After examining Mr. Veteran, his chart and medical records it is my opinion that Mr. Veteran is totally and permanently disabled due to the above discussed back condition. The veteran cannot hold gainful employment as a result of the injury he sustained while in the military. It is also my opinion that it is more likely than not the that the physical traumas suffered during the veteran's military service as noted in his record (description of events and dates) caused, contributed to and aggravated the totally disabling back condition(s).

Respectfully,

Dr. Physician, MD

Diplomat of the American Board of Internal Medicine

______________________________________________________________

The language in the example above is specific. Any language less specific may not meet the standard that VA will require.

Any physician who is qualified to write such a letter on your behalf may do so. While it is commonly believed that VA physicians aren't allowed to write such letters, that isn't true. VA physicians, as with many civilian physicians, simply don't like to write such letters as they are not skilled at the task, may not have the tools to write the letter at hand and they are often so busy caring for a heavy load of patients this is seen as work that isn't a priority.

It is perfectly acceptable for the veteran to write a letter on behalf of the physician and then ask the physician to sign it. In any setting, whether VA or civilian, the veteran is advised that he or she should not ask a nurse or clerk to perform the task of obtaining a signature for them. These ancillary members of the care team often see themselves as "gatekeepers" to guard and protect the physician from tasks that will only take up more valuable time.

They may believe that "rules" or "law" won't allow the physician to sign such a document and the veteran may be refused access to the doctor. It's best to make a routine appointment, wait until the veteran is face to face with the M.D. and ask that provider directly.

Most physicians will sign such a letter if it is brief, to the point and factual. When writing a nexus letter great care must be given to recording only facts and the doctor's conclusions.

There are physicians available who will perform records reviews and/or Independent Medical Examinations and provide opinions. Often these doctors do a very good job of providing a nexus letter if the veteran isn't otherwise able to obtain one.

The charge for such a letter from an independent physician can vary depending on the extent of the services. The veteran must pay that fee in advance with no guarantee that any award will be won. The Independent Medical Examining doctor does not treat or prescribe medications but only provides services of review and report.

Let’s be clear! 

Not all nexus letters, even those where the providers have used a phrase such as the veteran’s diagnosis of XXX is a result of his/her military service, which is equivalent to saying it is 100% a result of military service are acceptable evidence.

If the opinion in the nexus letter does not have a clear rationale behind the opinion, it’s basically a worthless piece of paper. Seeing a comment such as “based on my XX number of years as a board certified XXX, it is my professional opinion that the veteran’s diagnosis of XXX is a result of his her military service,” is also a fairly worthless piece of paper. The rationale for the opinion is far more important than the actual opinion itself.

If the provider doing the nexus letter does not include a review of the veteran’s service medical records (including positive and negative factors impacting the opinion) as well as all other medical records, it will have less probative value compared to the opinion of the C&P examiner, who will certainly have all of those records. Making an opinion based on partial facts (i.e., not having access to all records) does not help the case a great deal when compared to the opinion statement provided by the C&P examiner.

The importance of the nexus letter can't be overstated. In many situations, the nexus letter from an expert is the only evidence that will tip the scales in favor of the veteran.

In the C & P Service Clinicians Guide instructions are given to the examiner as to the exact phrasing that should be used, as follows here;

Q: How do I give an opinion for nexus (relationship to a military incident)?

A: When asked to give an opinion as to whether a condition is related to a specific incident during military service, the opinion should be expressed as follows:

1. “is due to” (100% sure) (SUCCESSFUL)

2. “more likely than not” (greater than 50%) (SUCCESSFUL)

3. “at least as likely as not” (equal to or greater than 50%) (SUCCESSFUL)

4. “not at least as likely as not” (less than 50%) (UNSUCCESSFUL)

5. “is not due to” (0%) (UNSUCCESSFUL)

That key phrase of "more likely than not" is right where the DRO wanted it.

The only thing missing from this letter is an often used statement to point out that there are no other known or apparent causes for the current condition. That might read like; "There is no known history of the veteran's family having this condition..." or "The veteran has no other known history that would cause or contribute to this condition...".

I only include that statement when the cause of the condition is less than apparent. I might use that to show that a cancer was more likely than not caused by exposure to Agent Orange and that the veteran had no family history or exposure to other carcinogenic chemicals that may be seen as a possible cause for the current condition. In this case, there were 2 documented traumatic events that were the likely cause of the injury making any reference to other possible causes unnecessary.

Remember, just because your Doctor writes a letter stating you have a medical condition that WILL NOT be enough to award you a disability benefit.

Your Doctor must write the condition MUST BE

  1. linked,
  2. caused/contributed or
  3. aggravated by your military service.

If you have a letter without this information your claim WILL MOST LIKELY be denied. We cannot stress this enough. Also, just because you are going to the VA for treatment for your condition that does not automatically qualify you for compensation. You will still need the "Nexus" letter and file a claim for compensation.

Most medical professionals are familiar with the concept of "medical certainty", which is a much higher standard than that required by the VA. As a result, private physicians may apply the wrong standard if the VA terms are not explained to them. Even then, a private physician may be reluctant to state a conclusion regarding nexus and, if they do may qualify their conclusion with terms such as "may", "could", "suggests", of "possibly". Doing this will “water down” the conclusion below the required 50% range and will not meet the VA's legal standard for establishing a nexus even though the physician actually believed the condition to be 50% or more likely service-connected. This "literary license" will cost the Veteran time and energy and money to get a rebuttal nexus.

To prevent such misunderstandings, a claimant should make sure that the medical professional asked to provide a nexus letter understands the importance of the letter and of using the specific "magic words" to correctly state the physician’s medical opinion.

 

Medical Nexus for Direct Service Connection

1) Provide a current diagnosis for injury/illness that you believe is the result of honorable service.

2) Ask a doctor to review your service records and ask if the injury / disease / illness could be linked to service with a medical nexus.

Example of direct service connection:

I have reviewed the Veteran's Service Medical Records and their current treatment records(s) and in my opinion "it is more likely than not" that the Veteran's (diagnosis) is related to their military duty. I base my opinion on this because (the doctor will write sound medical opinion).

_________________________________________________________

Medical Nexus for Secondary Service Connection

Medical Opinion for secondary/proximate Service connection:

1) Provide a current diagnosis for the injury/disease/illness that you believe is secondary/proximate to your service connected condition.

2) Get a doctor to link this injury/disease/illness to your service-connected condition with a medical nexus.

Example:

I have reviewed the Veteran's current treatment records(s) and in my opinion "it is more likely than not" that the Veteran's (diagnosis) is secondary and/or proximate to the Veteran's service-connected (condition). I base my opinion on this because (the doctor will write sound medical opinion).

 

NOTE: For a TDIU Claim (Total Disability based on Individual Unemployability) your conditions are already service connected so you do not need a nexus letter. You can, however get a physician’s unemployability letter stating the following:

A statement like this will help if you can get a doctor to write it out for you.

"After examining Mr/Ms Veteran, his/her chart and medical records it is my opinion that Mr/Mrs Veteran is totally and permanently disabled due to the above discussed back condition. The veteran can not hold gainful employment as a result of the injury he/she sustained while in the military. It is also my opinion that it is more likely than not that the physical traumas suffered during the veteran's military service as noted in his/her record (description of events and dates) caused, contributed to and aggravated the totally disabling back condition(s). "


How the heck do I ask my doctor to write this for me?

First, you need to understand that your PCP (Primary Care Physician), mental health provider or specialist's primary concern is your current health. If they CHOOSE to help you with a disability claim it may well be on their own time.  Speak with your provider and ask if it would be helpful to set another appointment specifically for the nexus letter.

Another point is that your care team has to keep the doctor/patient relationship in perspective. If they are not convinced that your condition is service connected, either as a direct service connection or secondary, they will not be able to write an effective letter. If the nexus letter is inadequate to secure service connection you may hold ill feeling toward your care team. That cannot be their focus as your current medical and mental health must be their primary focus. 

Can a VA doctor write a nexus letter?

Yes, they can. Will they? It is their choice. The VA Directive 1134 dated Nov 2016 states that a VHA (Veteran Health Administration) medical professional can and should write nexus letters as well as DBQs (Disability Benefits Questionnaire)

This is a copy of VA Directive 1134 Dated Nov 2016


Veteran’s Example Medical Nexus Opinion Letter Request to a Medical Professional

July 1, 2018

John D. Dingell VA Medical Center

Dr. Gregory House

4646 John R. Street

Detroit, MI 48201

Re:           Veteran, Frankie Sailor

                  D.O.B.: 7/25/61

Dear Dr. House:

I have a claim for the veteran’s disability benefits, and I am writing this letter to request a medical nexus opinion regarding my back condition.    

While serving in the Navy, I fell down a flight of stairs during a sexual assault.  I was treated for back problems following the attack.  Details of the fall and treatment during the service are found in my service medical records.  

Since my 1988 discharge, my back problems have been treated by a rheumatologist at the VA Medical Center.  Treating doctors at the VA facility have diagnosed me with the following conditions:

  • Cervicalgia with radiculopathy across both shoulders; 

  • Lumbago with radiculopathy down both lower extremities; 

  • Bilateral SI joint arthralgia; Myalgia, middle fibers of both trapezius muscles.  

I am hoping that you would be willing to review my records and provide an opinion regarding the cause of my back conditions for my VA disability claim.  

It is my belief that my fall down the flight of stairs during my attack caused my current back condition.  If a medical expert determines that it is “as likely as not” that my current back condition is linked to my service fall then my current back disability will be considered service-connected and my claim for benefits compensable.  

After reviewing my medical records please answer the following questions:

  1. Is it “as likely as not” that my current back condition is linked to my fall down the flight of stairs during my attack in service?

  1. What are the reasons and basis for your opinion?

The reasoning for your opinion is as important as your opinion.  Therefore, please indicate the documents you reviewed to reach your opinion and the facts on which you base your findings.  

Please find enclosed a copy of my disability claims file which includes my service and post-service medical records.  It is important to note in your opinion that you reviewed my claims file (C-File) or STRs (Service Treatment Records).  Please note that relevant portions of the claims file have been highlighted for your convenience.   

The veterans’ disability benefits system is unlike other legal proceedings in which medical opinions are requested.  If you choose to assist me you will not be called to testify in court proceedings or depositions.  Your opinion cannot be directly challenged and you cannot be cross-examined.  

If there is additional information that you believe may be useful to this claim or you have questions regarding this request, please contact me at your convenience.  Thank you for assisting me in pursuing the veterans’ benefits that I earned. 

Very truly yours,

Frankie Sailor

Enclosures


Advocate’s Example Medical Nexus Opinion Letter to a Medical Professional

July 1, 2018

John D. Dingell VA Medical Center

Gregory House, MD

4646 John R. Street

Detroit, MI 48201

Re:            Veteran, Mary Smith

                  D.O.B.: 1/25/72

Dear Dr. House:

I represent Ms. Smith in her claim for veteran’s disability benefits.  I am writing this letter to request a medical nexus opinion regarding her back condition.    

While serving in the Navy, Ms. Smith fell down a flight of stairs during a sexual assault.  She was treated for back problems following the attack.  Details of the fall and treatment during the service are found in her service medical records.  

Since her 1988 discharge, Ms. Smith’s back problems have been treated by a rheumatologist at the VA Medical Center.  Treating doctors at the VA facility have diagnosed Ms. Smith with the following conditions:

  • Cervicalgia with radiculopathy across both shoulders; 

  • Lumbago with radiculopathy down both lower extremities; 

  • Bilateral SI joint arthralgia; Myalgia, middle fibers of both trapezius muscles.  

Ms. Smith indicated that you would be willing to review her records and provide an opinion regarding the cause of her back conditions for her VA disability claim.  

It is my belief that Ms. Smith’s fall down the flight of stairs during her attack caused her current back condition.  If a medical expert determines that it is “as likely as not” that Ms. Smith’s current back condition is linked to her in service fall then her current back disability will be considered service connected and her claim for benefits compensable.  

After reviewing the veteran’s medical records please answer the following questions:

  1. Is it “as likely as not” that her current back condition is linked to her fall down the flight of stairs during her attack in service?

  1. What are the reasons and basis for your opinion?

The reasoning for your opinion is as important as your opinion.  Therefore, please indicate the documents you reviewed to reach your opinion and the facts on which you base your findings.  

Please find enclosed a copy of Ms. Smith’s disability claims file (C-File) which includes her service and post-service medical records.  It is important to note in your opinion that you reviewed Ms. Smith’s claims file (C-File) or STRs (Service Treatment Records).  Please note that relevant portions of the claims file have been highlighted for your convenience.   

The veterans’ disability benefits system is unlike other legal proceedings in which medical opinions are requested.  If you choose to assist Ms. Smith you will not be called to testify in court proceedings or depositions.  Your opinion cannot be directly challenged and you cannot be cross-examined.  

If there is additional information that you believe may be useful to this claim or you have questions regarding this request, please contact me at your convenience.  Thank you for assisting Ms. Smith in her pursuit of the veterans’ benefits she earned. 

Very truly yours,

Linda Agent, VA Accredited Claims Agent ID#

 

Enclosures


Edited 4/3/2019 DAH

August 6, 2019 - 8:54pm
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