What is a Nexus Letter?

February 18, 2022


In short, a Nexus letter is a letter from a qualified medical professional that connects a veteran’s in-service condition, injury, or exposure to their current disability. 

Frustrated veterans will often think that they need to run out and spend thousands of dollars on a Nexus letter before applying for VA Disability Benefits, but this is not necessarily true. Understanding what the concept of “Nexus” is, and how a Nexus letter may function in your case, can empower a veteran to take charge of their claim for VA Disability Compensation. 

VA Disability Compensation “Must-Haves”

As a refresher, when applying for VA Disability Compensation, a veteran must have three things:

  1. A current disability. Something must be wrong, whether that be a generalized complaint of pain in a particular area, to a specific diagnosis like diabetes.
  2. An in-service event, condition, or injury. This could be anything from an actual injury while on duty, to exposure to a harmful chemical or pathogen.
  3. A nexus between the current disability and the in-service event, condition, or injury.

A veteran establishes that they have a current disability by submitting either lay or medical evidence that they are experiencing some kind of disability. The in-service event, condition, or injury is established when the VA retrieves medical and service records identified by the veteran.

So How Does a Veteran Establish a Nexus?

A nexus can be established a few different ways, but sometimes it is not even necessary. Some conditions are presumptively caused by certain events in service. For instance, the VA has long held that if a veteran served in Vietnam, and they letter develop diabetes, the diabetes is presumptively caused by the Agent Orange they were likely exposed to during the conflict. The list of presumptive conditions grows from time to time as more scientific evidence comes out about the long-term effects of things like Agent Orange or Burn Pit exposure.

If the disability is not on the list of presumptive conditions as published by the VA, the veteran is going to need to establish a nexus. The VA is supposed to help as part of their duty to assist by sending a veteran to Claims and Pension Exam, or C&P Exam for short.

Who Does The C&P Exam?

In short, a medical professional. The medical professional conducting the C&P exam may or may not be a medical doctor. They might be a nurse practitioner (NP or FNP) or physician’s assistant (PA). For certain conditions, such as Post-Traumatic Stress Disorder (PTSD), the VA may use a psychologist, while they might use an Audiologist for tinnitus and hearing loss exams.

If a veteran applies for several disabilities, the VA will often have a single medical professional conduct several different exams and evaluations. It is not uncommon to see a Physician’s Assistant conduct a C&P of degenerative disc disease, cancer, and flat feet in the same exam. Having an unqualified C&P examiner can be problematic and grounds for an appeal.

In the past, the C&P examiner was often an employee at a local VA Medical Center. More recently, however, the VA has outsourced all of its exams

What Happens At a C&P Exam?

At a VA C&P Exam, a medical professional will complete a Disability Benefits Questionnaire or DBQ for short. The DBQ form contains a review of the symptoms and a measurement of the severity of the symptoms. Depending on the disability, the medical professional will take measurements to determine the range of motion or conduct an interview to collect information from the veteran.

If a nexus opinion is needed, the medical professional will also prepare a medical opinion, which, if done correctly, will state whether or not it is “as likely as it is not” that the current disability is related to the in-service condition.

The Disability Claimed is on the VA’s list of Presumptive Conditions, so Why Would a Veteran Need to go to a C&P Exam?

As noted earlier, the C&P exam serves two purposes: one is to determine a nexus, and the other is to measure the degree of disability experienced by the veteran. In other words, the VA is trying to determine how high of a rating the particular disability warrants.

Can a Veteran Get Their Own Nexus Opinion?

The short answer is yes. A veteran can always get their own physician to write a letter describing the level of disability as well as an opinion as to whether the current disability is related to the in-service condition, incident, or injury. 

The most effective nexus letters include the following:

  • A statement that the disability “is as likely as it is not” related to the specific injury, condition, or event in service.
  • A statement that the medical professional has reviewed the veteran’s medical records, including medical records from the veteran’s time in service, as well as their military personnel file.
  • A statement about what kind of exam the medical professional has conducted of the veteran.
  • A statement of the medical professional’s qualifications, as well as a curriculum vitae.
  • A brief, concise, but detailed statement as to the medical professional’s rationale as to why the current disability is connected to the in-service condition, event, or injury.

Should a Veteran Have to Pay for Their Own Nexus Letter?

Sometimes, a Veteran’s treating medical provider will write a letter as a courtesy (for free) or for a small fee. These opinions can carry a lot of weight with the VA, especially with the Board of Veterans Appeals, because it is presumed that the Veteran’s treating physician is extremely familiar with the Veteran’s condition.

A Veteran can also hire a medical expert to prepare an “Independent Medical Opinion,” or IMO. Since the Veteran is paying for the medical expert’s time, it is not uncommon for a doctor to charge well over $1000 for an opinion letter.

When getting a private medical opinion, it helps if the provider is a specialist in the field the Veteran is asking them to write about. For instance, if the question is service connection for cancer, it makes sense to find an oncologist. 

Develop a Strategy with an Experienced Veterans Disability Attorney

Before a Veteran opens their wallet and pays potentially thousands of dollars for a medical opinion, they should consider that the VA will send them for an opinion with a C&P examiner if their claim contains sufficient information regarding their current disability. If the Veteran receives a rating decision denying service connection, a private nexus letter might make sense, however, it might also make sense to challenge the C&P examiner’s credentials. However, if a Veteran’s physician will write a letter for them at no cost, that might be an appealing option as well.

In the end, it might help to consult with an experienced and accredited Veterans Disability Benefits Attorney to develop a strategy based on your particular case.