What is a Nexus Letter!

A Nexus letter is a formal document written by a licensed physical or mental healthcare professional that presents a medical opinion. It outlines your current diagnosis and establishes a link between your current disability and your military service.

When Do You Need a Nexus Letter?

The VA offers compensation to veterans who have incurred a disability due to their military service. For instance, many veterans were exposed to loud noise during service and subsequently developed tinnitus (ear ringing) and/or hearing loss. Because most veterans would not have likely complained about ringing in their ears during service, the VA requires a medical professional to examine the veteran and review the evidence and provide an opinion about whether the veteran’s current tinnitus/hearing loss was caused by their noise exposure during service. The VA is required to provide an examination and medical opinion on these cases free of charge to the veteran via a Compensation and Pension Exam (C&P) with an examiner hired by the VA.

Unfortunately, VA C&P examiners may provide a negative opinion that denies the veteran service connection for their current condition. This is where an independent nexus letter can be helpful – an independent reviewer will review your relevant files and scientific research regarding the subject and form an independent opinion. Medical professionals who write independent nexus letters are often highly educated on the latest research regarding the relevant disabilities and their causes, and often provide a much stronger, more detailed rationale for their opinion compared to VA providers who are often overworked and underpaid.

This is just one example of the type of claim that a Nexus letter can support. Nexus letters can support a direct connection of your disability to service, a secondary connection of a current disability that is caused by a service-connected condition (e.g. anxiety/depression caused by tinnitus/hearing loss); or an aggravation connection in which a non-service disability is made worse by a service-connected disability (e.g. non-service-connected sleep apnea made worse by service-connected PTSD).

It is not ALWAYS necessary to have a nexus letter, especially if this is the first time you are submitting a claim, but many veterans feel more comfortable submitting a claim with extra supporting evidence found in an independent nexus letter. For a supplemental claim and/or appeal of a denied claim, a nexus letter can provide crucial information and evidence that will strengthen your claim.

Who can write a Nexus letter?

This depends on the condition you are claiming. Nexus letters can be written by the healthcare professional who is treating your conditions (like your primary care physician) or by an independent healthcare provider who is trained to review records and provide nexus opinions.

For physical conditions such as back pain, tinnitus/hearing loss, acid reflux, sleep apnea, and more, a nexus letter should be written by a medical professional in that specialty area, OR, it can be written by your primary care physician if they are willing to create a nexus letter that meets the VA requirements for medical evidence. For instance, for tinnitus/hearing loss, you should get a nexus letter from an audiologist, or from a medical professional who has reviewed your audiology medical records and has the expertise to form an opinion based on those records. Sleep apnea requires sleep study by a sleep medicine specialist, etc.

Mental health conditions should be addressed in a letter by a high-level mental health professional such as a psychologist, psychiatrist, or psychiatric nurse practitioner. It is less advisable to have a master’s level counselor provide a nexus letter (such as a clinical social worker or mental health counselor) unless that person has been directly providing you with therapy sessions and understands the necessary components of an independent medical opinion required by the VA.

What should a good Nexus letter contain?

Credentials

The first portion of your nexus letter should contain information about the credentials of the letter-writer and information to support that they are providing an unbiased opinion regarding your case.

Reference

The second component of your Nexus letter should include information that the professional who created your Nexus letter has examined your medical records and reviewed any treatment documentation from the VA pertaining to your condition.

Medical Opinion

A crucial component of a Nexus letter is the inclusion of a medical opinion. This element is vital, as it outlines the connection between specific incidents during your active service and the development of your condition. Additionally, this section provides an overview of your current health issues, highlighting the most significant effects or symptoms you are experiencing.

Medical Rationale

The last essential component is medical justification. This includes references from medical research that demonstrate the basis for the doctor's determination that your health condition is connected to military service. The Board of Veteran Appeals has stated that “the probative value of a nexus opinion lies in its reasoning” – meaning, your doctor cannot simply state their opinion, but they must support their opinion with a logical rationale as to WHY they have that opinion. (See See Nieves-Rodriguez, 22 Vet. App. at 295 regarding a credible medical opinion - "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion").

Many physicians who are not trained in VA disability claims do not understand that this is an absolutely essential part of a credible nexus letter, leading to the rejection of their opinion by the VA because it doesn’t contain a sufficient rationale. This section should ideally include scientific research that supports the healthcare professional’s opinion.

How Many Nexus Letters Do You Need?

The number of Nexus letters required for filing a VA claim is dependent upon your specific health conditions. If you are seeking compensation for two separate issues, you will need to submit a separate letter for each condition. If you are filing a claim for a single issue, one Nexus letter will suffice.

Do VA Doctors Write Nexus Letters?

VA doctors typically decline to write nexus letters in support of their patients’ VA disability claims. As employees of the VA, they are unable to offer an impartial medical opinion. It is advisable to seek this letter from your private healthcare provider or from a healthcare professional who has been trained in providing independent Nexus letters.

Final Thoughts

The most important thing to note is that a nexus letter is NOT a requirement for a successful VA disability claim, especially if it is a brand-new claim. The VA has a responsibility to provide an examination and medical opinion free of charge. That said, if your initial claim is denied, or if you just feel more comfortable having additional evidence to support your claim, a nexus letter can be a valuable resource – but only if it is written by someone who is qualified to provide an opinion about your conditions and knows the specific language and components of a strong, credible nexus letter.

Looking for a mental health nexus letter?

If you’re searching for someone to provide a nexus letter regarding any disability related to mental health, please consider Dr. Deborah Miller. She is a licensed psychologist with years of experience providing exams and medical opinions for the VA and has been serving veterans directly with independent mental health exams and nexus letters to support veterans’ mental health disability claims. Click here for more information about her services.