Looking for Expert-Level VA Claim Help?📱Call Us Now! 737-295-2226
Fellow veterans, this is your ultimate guide to proving secondary service connection for VA disability benefits.
What’s the bottom line?
A Nexus Letter for a secondary condition is mission critical to getting your secondary VA claim approved!
In this high-value blog post from VA disability expert Brian Reese, we’ll explain what a Nexus Letter is for VA disability, the key elements of secondary service connection, the importance of a strong Nexus Letter for your secondary claim, and provide two sample Nexus Letters for secondary conditions.
Without further ado, let’s begin.
Table of Contents
Summary of Key Points
- A Nexus Letter is Mission Critical for a Secondary VA Claim: It’s a critical document that establishes the connection between a veteran’s new secondary condition and a current service-connected disability rated at 0% or more. A high-quality Nexus Letter significantly increases your chances of VA claim approval.
- VA Secondary Service Connection: Secondary service connection occurs when a new condition is caused or aggravated by an existing service-connected disability. Clear medical nexus evidence between the two conditions is required to prove this link to the VA.
- Three Key Elements for Secondary Service Connection: To succeed in a secondary VA claim, you need (1) a formal diagnosis of the new condition, (2) an existing service-connected disability rated at 0% or higher, and (3) strong medical nexus evidence linking the two.
- Legal Basis for Secondary Claims: Per 38 CFR § 3.310, secondary service connection can be granted for conditions caused or aggravated by a service-connected disability. This also includes aggravation of nonservice-connected disabilities beyond their natural progression.
What is a Nexus Letter for VA Disability Benefits?
A Nexus Letter is an evidence-based document (advisory type independent medical opinion) prepared by a private medical professional that helps to establish a link or connection (“nexus”) between the veteran’s current disability and their active-duty military service or to help prove secondary service connection and service connection via aggravation.
Pro Tip: Not all Nexus Letters carry the same weight with the VA. The probative value of a Nexus Letter depends on its quality, supporting evidence, and the credibility of the medical provider who wrote it.
What is VA Secondary Service Connection?
Secondary service connection occurs when a new condition is proximately due to, caused, or aggravated by a current service-connected condition rated at 0% or higher.
For example, let’s say a veteran is service-connected for a knee injury rated at 10%.
Over time, this service-connected knee injury might cause the veteran to change their gait and walk differently, leading to lower back problems.
In this case, the new lower back condition could be claimed secondary to the service-connected knee injury.
The VA requires clear medical nexus evidence that links the new secondary condition to the primary service-connected condition.
The best way to help prove the connection between two medical conditions is with a Nexus Letter from a private healthcare provider!
Pro Tip: If you’re filing a secondary VA claim, a Nexus Letter for a secondary condition is highly recommended. Why? Because secondary service connection requires “Medical Nexus Evidence” that your new disability is proximately due to, caused, or aggravated by a current service-connected disability. A Nexus Letter helps prove these requirements for your secondary claim to the VA.
38 CFR Secondary Service Connection: Legal Definition of Secondary Service Connection to Include Aggravation
According to 38 CFR 3.310(a) and (b), service connection can be granted for disabilities that are either directly caused by or aggravated by a service-connected condition.
This includes:
- Secondary Causation: Where the new secondary disability is proximately due to or the result of a current service-connected condition.
- Secondary Aggravation: When a non-service-connected disability is aggravated (e.g., made worse) by a service-connected disability.
How to Establish Secondary Service Connection for VA Disability
To establish secondary service connection for VA disability, you must prove three key elements:
#1. Medical Diagnosis of the New Secondary Condition:
You need a formal medical diagnosis of the new secondary condition in your medical records, whether from VA healthcare providers or private physicians.
It’s beneficial to have a current diagnosis within the past 12 months to show the condition’s ongoing impact.
#2. Existing Service-Connected Disability Rated at 0% or Higher:
You need evidence of an existing service-connected primary VA disability rated at 0% or more.
You’ll connect the new secondary condition to this service-connected primary condition in VA.gov.
#3. Medical Nexus Evidence Between the Two Conditions:
You need a strong Nexus Letter for a secondary VA claim.
This independent medical opinion should state that your new secondary condition is “at least as likely as not” caused or aggravated by your current service-connected condition.
A strong Nexus Letter from a private healthcare provider is often the missing link between a VA claim approval and a denial.
Two Sample Nexus Letters for Secondary Conditions
Sample #1: Nexus Letter for Obstructive Sleep Apnea (OSA) Secondary to PTSD
[Veteran’s Full Name]
[Veteran’s Social Security Number / VA Claim Number]
[Date]
To Whom It May Concern:
I, Dr. [Doctor’s Full Name], am a licensed medical professional specializing in [Specialty, e.g., Pulmonology, Sleep Medicine, Psychiatry, or Internal Medicine]. I have reviewed the medical history, relevant records, and conducted an examination of [Veteran’s Full Name]. My findings support that it is “at least as likely as not” (a probability of 50% or greater) that this veteran’s diagnosis of Obstructive Sleep Apnea (OSA) is secondary to their service-connected Post-Traumatic Stress Disorder (PTSD).
Medical and Service Background
[Veteran’s Full Name] is a [veteran’s branch of service, e.g., United States Army] veteran who served from [Service Start Date] to [Service End Date]. During their honorable service, [he/she/they] experienced significant traumatic events consistent with the development of PTSD, which was subsequently confirmed by the VA as service-connected.Since discharge, [Veteran’s Name] has suffered from chronic PTSD symptoms, including frequent nightmares, hypervigilance, anxiety, and an increased startle response. [He/She/They] has been under my medical care for [number] years for both PTSD and symptoms consistent with obstructive sleep apnea, which include severe daytime fatigue, loud snoring, and observed episodes of cessation of breathing during sleep, as reported by [his/her/their] partner.
Diagnosis
[Veteran’s Full Name] has been diagnosed with Obstructive Sleep Apnea (OSA) confirmed through [relevant sleep studies, e.g., polysomnography conducted on Date]. The study revealed an Apnea-Hypopnea Index (AHI) of [AHI value], indicating [severity level, e.g., moderate or severe] OSA. Additionally, the veteran’s diagnosis of PTSD has been documented as [e.g., “chronic and severe,” “persistent”] since [date of PTSD diagnosis].Medical Literature and Correlation
Current medical literature recognizes an established link between PTSD and the onset and exacerbation of sleep disorders, particularly Obstructive Sleep Apnea. Studies have shown that individuals with PTSD have a significantly increased risk of developing OSA due to factors associated with the physiological and psychological effects of PTSD. Notably, factors that contribute to OSA development include:
- Hyperarousal and Hypervigilance: Individuals with PTSD often have an elevated sympathetic nervous system response, which contributes to difficulty reaching and maintaining restorative sleep stages.
- Frequent Nocturnal Arousals and Fragmented Sleep: Due to nightmares, night sweats, and insomnia, individuals with PTSD frequently experience disrupted sleep, which exacerbates breathing irregularities and increases the risk of OSA.
- Increased Muscle Tone and Airway Obstruction: The elevated muscle tone in individuals with PTSD can lead to increased airway resistance and exacerbate airway obstruction, a primary feature of OSA.
Nexus Opinion
In my professional opinion, based on the veteran’s medical history, examination, and the substantial body of medical research linking PTSD and Obstructive Sleep Apnea, it is “at least as likely as not” that [Veteran’s Name]’s Sleep Apnea is aggravated by or secondary to their service-connected PTSD.
Supporting Medical Evidence
In my evaluation, I relied on the following supporting evidence:
- Veteran’s Reported Symptoms and Sleep History: [Provide specific symptoms reported, such as sleep fragmentation, frequent awakenings due to nightmares, and breathing pauses observed by partner, if applicable.]
- PTSD-Related Impact on Sleep and Health: [Discuss PTSD symptoms contributing to disrupted sleep, including anxiety, insomnia, etc.]
- Published Medical Research: Studies, such as [mention specific research if applicable, e.g., “PTSD and Increased Risk of Sleep Apnea in Veterans,” etc.], support a strong correlation between PTSD and OSA, showing that PTSD patients exhibit higher rates of sleep apnea compared to those without PTSD.
- Observations and Findings from Recent Evaluations: During my examinations of [Veteran’s Name], I observed [relevant clinical findings, e.g., fatigue, excessive daytime sleepiness, symptoms related to oxygen desaturation].
Conclusion
Given this evidence, it is my professional opinion that [Veteran’s Full Name]’s Obstructive Sleep Apnea is secondary to or aggravated by [his/her/their] service-connected PTSD. Therefore, it is recommended that the VA considers [his/her/their] Sleep Apnea as secondary to [his/her/their] PTSD for disability rating purposes.
Please feel free to contact my office at [Doctor’s Contact Information] if further clarification is required regarding my findings or if any additional documentation is necessary.
Thank you for your attention to this matter.
Sincerely,
[Doctor’s Signature]
[Doctor’s Printed Name]
[Doctor’s Title and Specialty]
[License Number and State]
[Contact Information]
Sample #2: Nexus Letter for Lower Back Condition Secondary to Knee Condition
[Veteran’s Full Name]
[Veteran’s Social Security Number / VA Claim Number]
[Date]
To Whom It May Concern:
I, Dr. [Doctor’s Full Name], am a licensed medical professional specializing in [Specialty, e.g., Orthopedics, Physical Medicine, Rehabilitation]. I have reviewed the medical history, relevant records, and conducted an examination of [Veteran’s Full Name]. Based on my evaluation, it is “at least as likely as not” (a probability of 50% or greater) that [his/her/their] diagnosed Lower Back Condition is secondary to [his/her/their] service-connected Knee Condition.
Medical and Service Background
[Veteran’s Full Name] served honorably in the [branch of service, e.g., United States Marine Corps] from [Service Start Date] to [Service End Date]. During [his/her/their] service, [he/she/they] sustained a [describe knee injury, e.g., right knee injury] that ultimately led to a diagnosis of [specific knee condition, e.g., chronic patellar tendinitis, knee osteoarthritis]. The VA has recognized this knee condition as service-connected.Since developing this knee condition, [Veteran’s Name] has reported chronic pain and instability in the affected knee, leading to an altered gait. Over time, [he/she/they] has experienced increasing symptoms in [his/her/their] lower back, including pain, stiffness, and difficulty with mobility. These lower back symptoms are consistent with a musculoskeletal condition related to compensatory postural and gait changes due to [his/her/their] knee condition.
Diagnosis
[Veteran’s Full Name] has been diagnosed with [specific lower back condition, e.g., lumbar spondylosis, degenerative disc disease, lumbar strain]. Imaging studies, including [specific imaging, e.g., MRI, X-ray] performed on [date of imaging], confirm the presence of this condition, showing [describe findings, e.g., degenerative changes in the lumbar spine, disc bulging, spinal misalignment].Medical Literature and Correlation
Medical literature strongly supports a biomechanical link between knee conditions and the development of lower back conditions. Studies show that individuals with chronic knee pain or instability often alter their gait to reduce knee discomfort. This compensatory change frequently places additional strain on the lumbar spine, leading to or aggravating lower back problems. Notably:
- Altered Gait and Compensatory Posture: Favoring one side due to knee pain often results in abnormal biomechanics, increasing the load on the opposite hip and lower back.
- Chronic Muscle Imbalance: Chronic knee pain can lead to muscle imbalances, which, in turn, place stress on the lumbar spine, contributing to conditions like lumbar spondylosis or degenerative disc disease.
- Increased Spinal Load and Degeneration: A shifted or uneven gait pattern can accelerate wear on the spinal joints and discs, which may lead to degenerative changes over time.
Nexus Opinion
In my professional opinion, based on [Veteran’s Name]’s medical history, the physical examination, and supported by current medical research, it is “at least as likely as not” that [Veteran’s Full Name]’s Lower Back Condition is secondary to [his/her/their] service-connected Knee Condition.
Supporting Medical Evidence
In my assessment, I relied on the following supporting evidence:
- Veteran’s Medical and Treatment History: Documented symptoms of knee pain and instability, including reports of altered gait and lower back pain developing after the knee condition.
- Objective Imaging Findings: Radiological evidence, including [MRI, X-rays, etc.], shows [list findings related to the lower back condition, such as degenerative disc changes, spinal misalignment].
- Published Medical Research: Numerous studies demonstrate the connection between chronic knee pain and compensatory postural adjustments leading to lumbar spine issues. For example, research shows that compensatory gait patterns due to knee pain significantly increase lumbar load, accelerating degenerative changes in the spine.
- Clinical Observations and Exam Findings: My examination of [Veteran’s Full Name] reveals [describe pertinent physical findings, such as limited range of motion in the lower back, tenderness, or abnormal gait], consistent with a lower back condition related to [his/her/their] knee impairment.
Conclusion
Based on this evidence, it is my professional opinion that [Veteran’s Full Name]’s Lower Back Condition is secondary to or aggravated by [his/her/their] service-connected Knee Condition. Therefore, I recommend that the VA consider the Lower Back Condition as secondary to [his/her/their] service-connected knee condition for disability rating purposes.
Please do not hesitate to reach out to my office at [Doctor’s Contact Information] for any additional information or clarification regarding my findings.
Thank you for your consideration of this veteran’s claim.
Sincerely,
[Doctor’s Signature]
[Doctor’s Printed Name]
[Doctor’s Title and Specialty]
[License Number and State]
[Contact Information]
Do You Need a Nexus Letter for Secondary VA Claim?
Trying to get a high-quality Nexus Letter to help service-connect your secondary condition?
WE GOT YOUR SIX!
Veterans who become members of the VA Claims Insider Elite program can get access to our preferred provider network who can potentially write VA Nexus Letters at reduced rates.
Why pay $1,500 to $2,000 for a Nexus Letter when you can get one for $595?
Click HERE to book a date and time to speak with a VA claim expert (no-obligation, no high-pressure sales tactics) or call us right now at: 737-295-2226.
Want Expert-Level VA Disability Claim Help? WE GOT YOUR SIX!
- VA Claims Insider is the #1 most trusted name in VA disability claims.
- Work directly with a VA claims coach who can help lead you to VA claim victory.
- 25,000+ disabled veterans served in our membership programs since 2016.
- 30% average rating increase for veterans who complete our #1 rated Elite program.
- 4.7/5.0 average rating out of 5,500+ total reviews; over 4,500 5-star reviews.
About the Author
Brian Reese
Brian Reese is a world-renowned VA disability benefits expert and the #1 bestselling author of VA Claim Secrets and You Deserve It. Motivated by his own frustration with the VA claim process, Brian founded VA Claims Insider to help disabled veterans secure their VA disability compensation faster, regardless of their past struggles with the VA. Since 2013, he has positively impacted the lives of over 10 million military, veterans, and their families.
A former active-duty Air Force officer, Brian has extensive experience leading diverse teams in challenging international environments, including a combat tour in Afghanistan in 2011 supporting Operation ENDURING FREEDOM.
Brian is a Distinguished Graduate of Management from the United States Air Force Academy and earned his MBA from Oklahoma State University’s Spears School of Business, where he was a National Honor Scholar, ranking in the top 1% of his class.
