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The Nexus Letter

By Jim Strickland

To win an award of a disability benefit, you must meet 3 criteria; You have to show eligibility by your military service, you must have a diagnosis of a condition and you must be able to provide evidence that the diagnosed condition had its origin during the time of your military service, or if the condition was preexisting, that it was aggravated by 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 article, 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 APC tablets 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."

Pain is good. If J.B. Books didn't complain about his back pain, why should you? You toughed it out, used a lot of aspirin and 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 and 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 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 winning the appeal. 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.

   Date

   VIA Certified Mail, Return Receipt

   Reference: Your full name
   Your reference numbers, SSN, etc.

   To whom it may concern;

   I am a (specialty) physician (Medical Doctor).

   I have reviewed the Service Medical Record of Veteran Josephine Sixpack as well as her more
   contemporary medical records and history.

   (If a physical examination has occurred, discuss that and report the findings now.)

   (Describe rationale. For example; This veteran has no known history of exposure to risk factors that
   may pose a risk for the hepatitis C virus. There are no tattoos and the veteran denies a history of
   multiple sexual partners, intranasal cocaine abuse, IV drug abuse, etc.

   I have concluded and it is my opinion that it is more likely than not that the veteran's current condition
   of (name the condition, illness, injury) was caused by (events) and during the time of military service.

   (Signed)

   Ima Quack, M.D.
   Address, etc.

   Enclosure; Curriculum Vitae

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 from about $1000.00 and up depending on th extent of the services. The veteran must pay that fee in advance with no guarantee that the physician will agree with the vet's assumption or that any award will be won. The Independent Medical exam doctor does not treat or prescribe and only provides services of review and report.

Update 09/26/2008

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;


1.16 How do I give an opinion for nexus(relationship to a military incident)?
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 # 1, 2, or 3 is apparent when we look at a recent letter that was used in an attempt to seek an increase in an existing benefit.

The veteran contacted me to ask for assistance after a DRO hearing. For the purposes of this exercise, the original nexus letter is shortened. It was very long. The email from the veteran is modified to correct grammar for ease of reading.  The intent of the message remains intact.

All of these documents are somewhat modified to protect the identity of the veteran, the VARO and the physician.

The initial email;

Jim;

Today I went to an appointment with a DRO at my VARO. This gentleman was very helpful and provided me with a lot of information.  However, he advised me not to go forward with a formal hearing and to instead have an informal hearing. He told me that he had some information he wants to share with me and then he advises me about the problem I having with my claims and the problems I am encountering with my appeals. He asked me to write a statement that I request an informal hearing and 30 day extension to submit new evidence. Then he turns all recording machine off, erases the tape and then look into my records.

Once he finished looking through my records, he explained that I need a new nexus letter to tie down the conditions to my military injuries. The problem he has with my current letter is that the letter is not specific to the point.

I'm not sure I understand what more he wants. The letter my doctor gave me includes everything about my injury. Can you help me?

Mr. Veteran


I'll point out that this is a reason I like the DIY method of handling a claim as well as the DRO process. This is more or less how the system should work. The VA employee is doing his best to assist the veteran to reap the maximum benefit he deserves.

Here is the original 'nexus letter' that the DRO wasn't happy with;


Date

Subject: Medical history of
Mr. Veteran

Reference: C-File #

To who it may concern:

I am the primary care provider for Mr. Veteran. In my capacity as a primary care provider, I have cared for Mr. Veteran since Date.

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 19xx. The results of this injury have been long lasting and his condition has worsened as he has gotten older.

For the past twenty-seven years since his first accident with unset while on active duty Mr. Veteran has suffered from increasing pain, diminished ability to walk, exhausted very easy, very frequently experience shortness of breath episodes, HBP, DMII, chronic Sinusitis condition, HCL, GERD Acid Reflux, Anxiety & Major Chronic Depression, Cervical Strain, upper extremities radiculopathy, Low extremities radiculopathy, Hip pain, including radiation to back of R & L legs, also R & L knee pain and discomfort, R & L ankle instability, r/arm shoulder discomfort, sc lumbar paravertebral myositis and continues to undergo treatment by me, VA clinic, and others specialty clinic and private medical specialists and physicians.

Mr. Veteran’s treatments and medications are as follows;

Physical Therapy, on many occasions; Mr. Veteran were referred when he was on active duty according to his active military file, here and by his prior VA doctors and also in the VA Medical Center in another State. Doctor’s have provided Mr. Veteran with many required assistance devices such as walking cane, walking crutches, walking Canadian crutches, quad walker, rolling walker w/seat, ten’s unit, lumbrosacral corset with metal stays, ankle air cast, and capsaicin/ trixaicin (topical analgesic cream).

Prescribed Medications: Oxicodone 20/10 mg, Etodolac 400 mg, Gabapetin 300 mf, Orphenadrine 100 mg, Metformin hcl 1000 mg, Sinvastatin 80 mg, Lisinopril 20 mg, Omeprazole 20 mg, Docusate ca 240 mg, Omega III 1000mg, Quetipine Fumarate 200 mg, Cymbalta 60 mg, Venlafaxine hcl 75 mg, Cyanocobalamin 1000 mg, Sulfameth/ Trimethoprin 800/160 tabs, Azelastine hci 5mg, Triamcinolone acetonide 6.5 mg, Gilprex TR, Cefuroxime 500 mg, Medrol Dosepak 4 mg, Avelox 400 mg, and Nasonex 50 mcg/inh spray.

I have observed that Mr. Veteran has challenges with functions of daily living and requires assistance. Mr. Veteran is not able to prepare meals for himself although he is able to feed himself. He is unable to participate in housecleaning activities and requires someone to do his laundry and dishes and generally keep his environment clean for him. .

Mr. Veteran has chronic pain due to his injuries and requires Oxicodone 20 mg, Etodolac 400 mg, Gabapetin 300 mf, Orphenadrine 100 mg which often has a side effect of dizziness and nausea. His pain level is often quite high with reports of 8 (eight) on a scale of 10 (ten). Prompting my self and other physicians to issue bed rest for more than six week so far this year.

Mr. Veteran has hypertension that requires Lisinopril 20 mg and this medicine can have the side effects of a slower heart rate or dizziness as well as frequent and urgent urination. Mr. Veteran must always be near a restroom in case of an urgent need to use that facility.

Mr. Veteran gets very fatigued because of the pain that is caused by any strenuous activity. Mr. Veteran is unable to lift more than 10 pounds consistently and can not push or pull more than 10 pounds consistently. Standing for long periods of time more than 15 minutes will make him become weak and exhausted. He is unable to reach overhead with his right hand due to pain or to bend at the waist to retrieve fallen items. Bending action will upset his equilibrium and may cause him to fall.

I have examined Mr. Veteran’s chart and medical record and it is my opinion that there is a medical nexus between Mr. Veteran's active duty service connected injuries and his disability of today. It is also my opinion that Mr. Veteran is totally and permanently disabled, can not hold gainful employment as a result of his service-connected disabilities and is not a likely candidate to be rehabilitated.

Dr. VA Physician, MD
At The VA Clinic


The above is a very well written letter. Again, I've shortened it as it was very long and detailed. While some systems want great detail and long descriptions, the VBA wants to see the specific phrases that they require.

This letter would perfectly satisfy the Social Security Administration in an SSDI determination and likely would be more than enough for any civilian employer's disability insurance carrier.

Although it states that, "there is a medical nexus between Mr. Veteran's active duty service connected injuries and his disability of today" it does not state the degree of probability of such.

I modified the letter as follows;


Date

Subject: Medical history of
Mr. Veteran

Reference: C-File #

To who it may concern:

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 his service-connected disabilities.

It is also my opinion that it is more likely than not the that the physical traumas suffered during the veteran's military service and 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 letter I wrote is shorter. It's focused on the primary condition that is causing the veteran to be unemployable. Other conditions and the long list of medications are available to the reader but aren't central to the adjudication and aren't crammed in here causing the reader to lose focus.

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.