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The Nexus Letter

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 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.

 


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 posterocentral 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 can not 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. VA 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 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%)


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 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.

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.