In this post, I break down how veterans can fail-proof their VA nexus letter, which will help them prove that their disability is related to their military service or to another service-connected disability.
I’ll be revealing tips, strategies, and lessons learned after analyzing over 1,000 winning nexus letters written by competent and credible medical professionals.
Okay, but first, let’s break-down this simple, one-word, and yet, confusing term called a “nexus.”
According to the VA, a “nexus” is nothing more than a logical link or connection between a veteran’s current disability and an in-service incident, event, or injury.
In order to be eligible for VA disability compensation benefits under the law, a veteran must prove that their disability was caused or made worse by their active duty military service.
Many veterans get denied service connection by the VA because they failed to show a clear nexus (logical link or connection) between a current disability and their active duty military service.
But regardless of how many times you’ve been denied service connection, there is still hope!
Enter the VA nexus letter.
In our experience, a well-crafted nexus letter is the single most crucial document a veteran can provide the VA Rater to help prove service connection on an “at least as likely as not” basis.
Yep, it really is the single, most powerful way to prove service connection.
What is a Nexus Letter?
- A Nexus Letter is an evidence-based document prepared by a competent and credible medical professional that helps to establish a “connection” between the veteran’s current disability and their active duty military service.
A Nexus Letter is often the “essential” piece of evidence needed to help a veteran get their VA disability service connected.
So now I’ve probably got you wondering: “Brian, why are VA nexus letters so effective at proving service connection under the law?”
Awe yes, I’m glad you asked.
Simply put, it’s because VA disability claims are won or lost based on medical evidence.
Either you have enough medical evidence, or you don’t.
A great VA nexus letter IS medical evidence and can influence the C&P examiner’s medical opinion, as well as the VA Rating Official’s final disability decision, due to the medical nexus evidence provided in the letter.
Top 5 VA Nexus Letter Tips
- Tip #1: Use the doctor’s letterhead
- Tip #2: Keep your nexus letter short and sweet
- Tip #3: Have the doctor review your medical records (and explain it in the nexus letter)
- Tip #4: Cite relevant medical research and case law to support the conclusion
- Tip #5: The best medical nexus opinions include the words “more likely than not”
Tip #1: Use the doctor’s letterhead
This is a simple and effective way to instantly enhance the credibility of your nexus letter.
Because medical nexus evidence needs to be credible.
One of the best ways to enhance the credibility of the medical nexus letter is to list the doctor’s name and credentials at the top of the page.
Thus, before the C&P examiner and the VA Rater read the contents of the nexus letter, they already believe it was written by a credible medical professional.
With credibility on-the-line, don’t wait until the end!
Tip #2: Keep your nexus letter short and sweet
In our experience, a shorter nexus letter is better and more actionable for the VA Rater, so long as it meets the four essential elements listed below.
Why do I say this?
Well, because VA Raters are busy people.
Your VA claim is just one of 15 or so cases they rate on a given day, so the easier you can make it for them to read and analyze, the better chance you have of getting your disability service connected.
Thus, a winning VA nexus letter should be as brief as possible while stating facts and evidenced-based rationale, leading to a proper medical nexus opinion and conclusion.
Tip #3: Have the doctor review your medical records (and explain it in the nexus letter)
I’m often surprised (and disappointed) with the number of medical professionals who fail to explain the evidence he/she reviewed when writing a VA nexus letter.
It’s almost like writing a research report without citing your sources.
Because it diminishes the credibility of the evidence.
Instead, the doctor should reference any and all medical records or personnel records reviewed, such as, service treatment records, VA medical records, private medical records, DD 214, lab reports, or any other existing evidence of record.
For example, the doctor should say something like, “I have personally reviewed the veteran’s medical history, to include service treatment records and their current VA medical records, spanning from 2007 to present.”
Again, this provides and instant boost in credibility, because now the doctor’s nexus opinion can be backed-up with supporting medical evidence.
Tip #4: Cite relevant medical research and case law to support the conclusion
In general, it’s a good idea to have the doctor cite appropriate medical research reports and even case law to help support his/her position on how your disability is due to your service (or to another service connected disability for secondary service connection).
For example, if you’re trying to connect Sleep Apnea secondary to PTSD, you’ll want to ensure the VA nexus letter includes appropriate medical research studies and any case law regarding “aggravation” and the link between Sleep Apnea and PTSD.
At VA Claims Insider, we recommend citing at least two medical research reports and one to two BVA case law decisions to help support the medical nexus conclusion.
We recommend using PubMed.gov which is a free government website with more than 30 million medical research reports and citations for biomedical literature from MEDLINE, life science journals, and online books.
For BVA case decisions, we recommend using the Department of Veterans Affairs index of Board of Veterans’ Appeals Decisions.
You can freely search for BVA case decisions by keywords and date.
Tip #5: The best medical nexus opinions include the words “more likely than not”
In our experience, the best VA nexus letters use the medical opinion “more likely than not” NOT “at least as likely as not.”
The reason why “more likely than not” is better than “at least as likely as not” is because the former is a stronger statement with a higher probability.
The VA nexus opinion “more likely than not” means the medical professional believes there is a greater than 50% chance that a veteran’s condition was caused or made worse by active duty service or by another service-connected disability for secondary service connection.
Whereas, the statement “at least as likely as not” means the doctor thinks there is an approximate even balance of medical evidence for and against, and thus, there is a 50/50 chance that a veteran’s condition was caused or made worse by active duty service or by another service-connected disability for secondary service connection.
While veterans need only to prove their disability is “at least as likely as not” related to their service, the term “more likely than not” helps protect a veteran against a terrible C&P examiner who may write something like “less likely than not” due to service.
In the above scenario, the medical evidence is now in “relative equipoise,” which just means that the number of acceptable items of evidence tending to support a fact is equal to the number of items tending to not support a fact.
In this scenario, with all things being equal, the tie “should” go to the veteran (emphasis on should), or at a minimum, the VA Rater should order a second C&P exam to clear-up any evidence in question.
4 Essential Elements of a Nexus Letter
VA Nexus Letter Part #1: List any supporting evidence reviewed
The nexus letter doctor should reference any medical or personnel records reviewed, such as service treatment records, VA medical records, private treatment records, DD 214, or any other existing evidence of record.
Nexus Letter Part #2: Offer supporting evidence-based rationale
The best VA nexus letters list any medical research studies, scientific journals, or previous BVA case law precedent that describes the medical etiology of the veteran’s condition.
This is very important for direct service connection, secondary service connection, and presumptive service connection because medical etiology, also known as a “showing of causation,” is very important to help a veteran prove service connection.
Nexus Letter Part #3: Give a strong medical opinion
Make sure the medical professional writes one of five statements of likelihood in the VA nexus letter in order to help the veteran prove service connection under the law, preferably, the words “more likely than not.”
VA Nexus Letter Part #4: List credentials, such as job title or specialty
The doctor must sign and date their name, in addition to listing his/her medical credentials, such as, Oncologist, Orthopedic Surgeon, Sleep Specialist, PA-C, MD, etc.
This is a very important part of the VA nexus letter because it helps the VA Rating Official determine if it’s credible and competent for rating purposes.
The 5 Statements of Likelihood for a VA Nexus Letter
When asked to give an independent medical opinion as to whether a veteran’s condition is related to a specific incident during military service or another service-connected disability, the medical professional must express his/her medical nexus opinion with one of the following 5 statements of likelihood:
Nexus Statement #1 “Is due to” (100% sure)
The nexus opinion “is due to” means the doctor is 100% certain that a veteran’s condition was caused or made worse by active duty service or by another service-connected disability for secondary service connection.
This statement is highly unlikely because a doctor will rarely, if ever, be 100% certain.
VA Nexus Statement #2 “More likely than not” (greater than 50%)
The nexus opinion “more likely than not” means the doctor believes there is a greater than 50% chance that a veteran’s condition was caused or made worse by active duty service or by another service-connected disability for secondary service connection.
Nexus Statement #3 “At least as likely as not” (equal to 50%)
The nexus opinion “at least as likely as not” means the doctor thinks there is an approximate even balance of medical evidence for and against, and thus, there is a 50/50 chance that a veteran’s condition was caused or made worse by active duty service or by another service-connected disability for secondary service connection.
This is the minimum nexus statement that will help a veteran prove service connection, because the benefit of the doubt always goes to the veteran according to VA law.
When all things are equal, the tie goes to the veteran.
Nexus #4 “Not likely due to” (less than 50%)
The nexus opinion “not likely due to” means the doctor thinks there is a less than 50% chance that a veteran’s condition was caused or made worse by active duty service or by another service-connected disability for secondary service connection.
This statement will likely cause the VA Rater to deny service connection, unless one or more other medical opinions carry more weight or contain different medical opinions.
VA Nexus #5 “Is not due to” (0% chance)
The nexus opinion “is not due to” means the doctor thinks there is a 0% chance that a veteran’s condition was caused or made worse by active duty service or by another service-connected disability for secondary service connection.
This statement will cause the VA Rating Official to deny service connection.
About the Author
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).