The Nexus Letter

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

• You have to show eligibility of your military service.
• You must have a current medical diagnosis of a condition or a disability.
• You must be able to provide evidence that the medical 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.

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.

For the purposes of this 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 IBU Profen 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. "Pain", we learn, "is weakness leaving your body." 

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.

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 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.

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 the 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.

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)

      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%)

https://www.benefits.va.gov/benefits/mstcoordinators.asp