VA Disability - Step 6: When the initial decision finds no "nexus"

What is the "nexus" and why is it important? 

To get benefits, you must meet three tests. You need to show:

  • eligibility by your military service,
  • diagnosis of a "condition," and
  • evidence that the condition started during your military service or, if your condition was preexisting, that it was aggravated by military service.

This third test is the connection or "nexus" between what happened to you in the military and your current medical condition.

Case in point: the back injury story

In many cases this connection, or "nexus" may be tenuous at best. Let's consider, for example, 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.  You were given some APC tablets and sent on your way to light duty for 3 days. The back became 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. Your light duty was increased to  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. Fellow soldiers will know that they have to carry your load as well as their own. "Pain", we learn, "is weakness leaving your body." Pain is good. If J.B. Books [John Wayne character in the 1976 movie "The Shootist"] didn't complain about his back pain, why should you?

So you toughed it out, used a lot of aspirin. While your back did improve, you always guarded it and were cautious that you didn't injure yourself again. Your civilian career wasn't as physical as the military. So during the years since your ETS you've had a chronic, low level 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 disks and nerves. 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, your condition today is new and unrelated to those old problems. Now what?

How do I prove this "nexus"?

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

Your next task is to seek an expert physician who will review your complete medical records. You'll ask him or her to write a letter stating their opinion that your condition today is related to your military service. 

Any physician who is qualified to write a "nexus" 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. They may not be skilled at this task or may not have the tools at hand to write the letter. And typically they are so busy caring for a heavy load of patients that your issue isn't a priority.

What does the letter look like? 

The nexus letter should follow a similar format to all letters that you use to communicate to VA. It should record only the facts and the doctor's conclusions. It may be addressed directly to you or "To Whom It May Concern." Also, see if the physician is willing to provide you with a current resume to attach to the letter; this will help to support the physician's expertise.  View sample letter.

Note the specific language in the opening and closing paragraphs. Less specific language may not meet the VA standard.  The C & P Service Clinicians Guide  gives the examining physician the exact phrasing to be used in the "nexus" statement. Here is the relevant section of the Guide:

"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)
  2. “more likely than not” (greater than 50%)
  3. “at least as likely as not” (equal to or greater than 50%)
  4. “not at least as likely as not” (less than 50%)
  5. “is not due to” (0%) "

The importance of using the language  at # 1, 2, or 3 is apparent.

Here is another sample letter.  Again, note the "more likely than not" language in the "nexus" statement. Also, notice that the other medical information is pared down to the essential facts. Here is another note about this letter from it's author,  Jim Strickland: "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 veterans 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."

How do I get a doctor to support my claim?

It's best to make a routine appointment and meet face-to-face with the doctor. Ask her directly to draft or sign the letter.  Assuming that the physician agrees with your "nexus" claim, it is perfectly acceptable for you to draft the letter on her behalf. Then ask her to review and sign it, or edit and then sign, if she feels more comfortable with that. I advise you not to ask a nurse or clerk to perform the task of getting the physician's signature. These 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 may refuse you access to the doctor.  Most physicians will sign such a letter if it is brief, to the point and factual.

What if I can't find a doctor who wants to do the letter?

Some physicians are specialists who perform records reviews and/or Independent Medical Examinations and provide opinions. These doctors usually do a very good job with writing nexus letters, assuming that you can't get one some other way. These independent physicians can charge from about $1000.00 and up, depending on the extent of the services. You must pay that fee in advance with no guarantee that the physician will agree with your theory or that you will get benefits. The Independent Medical Exam doctor does not treat or prescribe and provides only a records review and report.


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 your favor. 

June  2010