Nexus Letters for VA Claims

June 18, 2024 – Nexus letters for VA claims - Mark D Worthen PsyD (Dr. Worthen) can provide an expert witness opinion regarding service connection for PTSD and other mental disorders in select cases.

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I will proffer an expert opinion about the nexus between a veteran's military service and his or her current psychiatric disorder only after conducting a thorough psychological evaluation.

I can conduct the evaluation in-person in Charlotte, North Carolina or via telehealth if you live in a PSYPACT® state.

I use the term "nexus letter" to mean a psychological evaluation report and DBQ that includes my expert opinion about the connection between a veteran's military service and his or her current mental disorder, or between a current service-connected medical condition and a mental disorder.1 

I will review relevant records first, for a $300 fee, and then let you know if I think an independent psychological exam (IPE) might support your claim. I will not write a nexus letter based on a  record review alone.

If we both agree to proceed with an independent psychological examination (IPE), the total cost is $3000, payable in advance ($2700 to proceed with an IPE, plus the $300 already paid for a record review). Other than some common sense exceptions, all fees are nonrefundable.2 

If I conduct an IPE, I will complete the relevant Disability Benefits Questionnaire (DBQ)* and write a psychological evaluation report. I can conduct independent psychological exams via video but only if you live in a PSYPACT® state.

→ Be sure to read: Do You Need a Nexus Letter?

*Except for original (initial) PTSD claims, for which VA prohibits independent examiners from completing the Initial PTSD DBQ, but in that case Dr. Worthen will provide all the information required by the Initial PTSD DBQ in the narrative report with specific reference to each DBQ item, using the same section numbers as appear on the DBQ for easy cross-reference. For more information, see Should a Private Examiner Complete an Initial PTSD DBQ?

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Important Considerations

Please understand:

  • I provide nexus letters for VA claims only after conducting a comprehensive independent evaluation.

  • I perform objective, unbiased exams. I am not on your side. I am not on VA's side. I am an independent examiner. 

  • I have credibility because of this objectivity and independence. I am not just trying to make money writing unrealistically favorable exam reports.

  • If you do not think my evaluation will help your claim, you do not have to use it, although you do have to pay for it.

  • I can conduct a Tele-C&P exam via secure video, but only if you live in a PSYPACT® state.

  • Most veterans filing an original (initial) claim for PTSD or other mental disorders do not need a nexus letter.

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These consent forms (a generic term) are for review only. Do not sign any of these forms now as I update them regularly. 

Therefore, keep in mind that if you retain me for an IPE, the consent forms I ask you to sign might differ from these example forms. These are simply examples.

I post these documents here to give you a better understanding of the type of exam I conduct, my obligations to you if you retain me to conduct an IPE, and your obligations to me. 


What is a Nexus?

A nexus is "a connection or link between things."3 

Nexus = Connection

Sometimes it is a causal connection. Post-Traumatic Stress Disorder (PTSD) is the best example of a causal connection. Traumatic events during military service often cause PTSD.

But the connection does not have to be causal. If a disease or injury was “incurred coincident with service in the Armed Forces,” that disease or injury is "service connected" (if it causes functional impairment).4  

Thus, nexus letters for VA claims can help in select cases if your mental disorder was caused by military service, developed during your military service, or was aggravated by military service.

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What does "incurred coincident with service" mean?

Incur is an important word in veterans law, but it is a strange word.

Incur means "to run or fall into (some consequence, usually undesirable or injurious)."5

Synonyms for incur include acquire and contract, like, "I acquired this rash when deployed to jungles in Central America" or "I contracted the flu at my kid's daycare."

So, a nexus is a connection between military service and a disease or injury. It might be a causal connection, but it does not have to be.

For example, if you developed clinical depression during military service, you do not have to prove that military service caused the depression.

You simply need to prove that your depression began during military service.

Or, in the language VA uses, if your depressive disorder was incurred coincident (at the same time as) your military service, then it is (or should be) a service-connected condition (provided it causes functional impairment). 

In addition, if you had a depressive disorder before enlisting, and military service aggravated your depression (made it worse), then your depressive illness is (or should be) considered a service-connected disorder (provided it causes functional impairment).6 

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Effective 1 October 2024, my fee increased to $3000 for an IPE.

After you have read this entire page, if you want me to review your records:

  1. Remit payment ($300).

  2. Submit your documents.

Remember that I cannot write a nexus letter based on a record review alone.

The purpose of the record review is for me to analyze your records to determine if a comprehensive psychological evaluation might help your claim.

I do not want you to spend hundreds or thousands of dollars for a psychological evaluation if the odds are low that the evaluation will help.

If you have questions, contact me. (Please read this entire page before contacting me.)

If you qualify, you may schedule a complimentary 15-minute consultation call. Complete this form to request the scheduling link. (The form lists the qualification criteria.)

→ Be sure to read: Do You Need a Nexus Letter?

Nexus Letters for VA Claims: Definition of Terms

"The beginning of wisdom is the definition of terms." - Socrates†

In this context, medical opinion, nexus statement, and expert witness opinion mean the same thing.

A nexus is "a connection or link between things, persons, or events."7 

A nexus statement is an expert's opinion about connection, i.e., service connection. (The Veterans Benefits Administration makes the decision about service connection).

Here is an example of a nexus statement:

"It is more likely than not that the veteran's major depressive disorder is proximately due to or the result of her post-traumatic stress disorder."

A nexus letter for VA claims contains one or more nexus statements. 

I use the term, nexus letter to mean a carefully completed DBQ* and a detailed narrative report, both based on an evidence-based, comprehensive psychological evaluation.8 

I use the term expert witness because, as the U.S. Court of Appeals for Veterans Claims explained: "Both VA medical examiners and private physicians offering medical opinions in veterans benefits cases are nothing more or less than expert witnesses."9 

VA uses the term medical opinion, whether or not the examiner has a medical degree, e.g., psychologists conduct most C&P exams for PTSD and other mental disorders, but our expert witness opinions are called medical opinions by VA even though we have a Doctor of Psychology (PsyD) or Doctor of Philosophy (PhD) degree.

---

†Although people usually attribute this aphorism to Socrates, he likely did not say it, at least not in this way.

*Except for original (initial) PTSD claims, for which VA prohibits independent examiners from completing the Initial PTSD DBQ, but in that case Dr. Worthen will provide all the information required by the Initial PTSD DBQ in the narrative report with specific reference to each DBQ item, using the same section numbers as appear on the DBQ for easy cross-reference. For more information, see Should a Private Examiner Complete an Initial PTSD DBQ?

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Request a Record Review

→ Effective 1 October 2024, my fee increased to $3000 total. ←

If you are a veteran seeking nexus letters for VA claims, please talk with your Veterans Service Officer, VA-accredited Claims Agent, or Veterans Law Attorney, and ask for their advice before requesting a Record Review.

If you and your representative believe you are ready for a Record Review by Dr. Worthen:

(1) Remit the $300 fee via the payment page.

(2) Submit your documents for me to review.

Note: If after reviewing your records, I believe an IPE (independent psychological exam) might support your claim, I will send you a link to pay the remaining $1800 of the retainer fee. If an IPE is unlikely to support your claim, we will not proceed further. You will have paid me $200 for the record review and that's it. 

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A-10 Thunderbolt "Warthog"A-10 Thunderbolt "Warthog"

Do You Need a Nexus Letter?

Many people say you should obtain nexus letters for VA claims before you file an original (initial) claim for VA disability benefits. But I doubt it's worth the money to pay someone for a nexus letter when you don't have to pay anything for the VA claim exam and the odds of winning your claim exceed 70%.10

Most vets don't need a nexus letter, but most vets do need a Veterans Service Officer.

Veterans Service Officers

Here's what VA says about Veterans Service Officers:

If you need help filing a claim or appeal, you may want to work with a Veterans Service Officer (VSO). We trust these professionals because they’re trained and certified in the VA claims and appeals processes and can help you with VA-related needs. VSOs work on behalf of Veterans and service members—as well as their dependents and survivors.

Search for a Recognized Veterans Service Organization (VSO) by state, city, or zip code on the VA's eBenefits website.

Also ask other veterans if they know of a good Veterans Service Officer. 

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Effective 1 October 2024, my fee increased to $3000 for an IPE.

After you have read this entire page, if you want me to review your records:

  1. Remit payment ($300).

  2. Submit your documents.

Remember that I cannot write a nexus letter based on a record review alone.

The purpose of the record review is for me to analyze your records to determine if a comprehensive psychological evaluation might help your claim.

I do not want you to spend hundreds or thousands of dollars for a psychological evaluation if the odds are low that the evaluation will help.

If you have questions, contact me. (Please read this entire page before contacting me.)

If you qualify, you may schedule a complimentary 15-minute consultation call. Complete this form to request the scheduling link. (The form lists the qualification criteria.)

→ Be sure to read: Do You Need a Nexus Letter?

What If I Don't Want a Representative?

I understand that some veterans and family members prefer to handle their disability claims themselves, without a representative.

You certainly have that right, and I have known several veterans and family members who have studied VA disability claims laws, regulations, policies, and procedures, and do an excellent job representing themselves.

However, representing yourself requires a lot of study and preparation.

Specifically, you will need to devote at least 50 hours to reading, asking questions,  searching the Internet, and consulting reference librarians for information.

If you have done your homework, and you choose to represent yourself, I will respect your autonomy and work with you.

However, if you start to ask me questions that any Veterans Service Officer would know the answer to, then I will stop and insist that you retain a Service Officer, Claims Agent, or Veterans Law Attorney.

That might sound harsh, but I want you to have competent, effective representation.

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Definition of "nexus"Screenshot from OED Online - the famous Oxford English Dictionary

Effective 1 October 2024, my fee increased to $3000 for an IPE.

After you have read this entire page, if you want me to review your records:

  1. Remit payment ($300).

  2. Submit your documents.

Remember that I cannot write a nexus letter based on a record review alone.

The purpose of the record review is for me to analyze your records to determine if a comprehensive psychological evaluation might help your claim.

I do not want you to spend hundreds or thousands of dollars for a psychological evaluation if the odds are low that the evaluation will help.

If you have questions, contact me. (Please read this entire page before contacting me.)

If you qualify, you may schedule a complimentary 15-minute consultation call. Complete this form to request the scheduling link. (The form lists the qualification criteria.)

→ Be sure to read: Do You Need a Nexus Letter?

Footnotes

1. Although less common, I also evaluate veterans for aggravation of a pre-existing mental disorder (38 C.F.R. § 3.306).

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2. What are "common sense exceptions" to the nonrefundable fee policy? If we have scheduled an initial evaluation session (usually via teleconference as long as you live in a PSYPACT® state), but you change your mind, I will refund the $1800 minus time spent preparing for the evaluation at a rate of $200 per hour.

Preparation tasks include email, text, and telephone communication; arranging online psychological test administration; and beginning to write the report, e.g., background information, medical and psychiatric treatment history, social history, previous C&P exams, military personnel records, etc.).

After you have provided all relevant documents (if you are not sure what is relevant, please ask your Veterans Service Officer), and after we have completed all exam components (interviews, psychological testing, etc.), I will give you a date for report completion, i.e., you will receive a complete draft report for your review on or before the date I give you.

The time frame can vary, but I will usually finish the complete draft report in three weeks from the date we have completed all evaluation components.

I call it a "draft" report because I want you to review it first so I can correct any factual errors and to flag anything I have not explained clearly. After you give me feedback, I will complete the final report (and DBQ) within a specified time frame (usually one week or less).

If I miss either of those deadlines, I will refund back to you $100 for every calendar day I am late. 

Note: I devote 15 hours or more to conducting a comprehensive, evidence-based psychological evaluation, which includes carefully completing the DBQ and writing a detailed report that supplements and supports conclusions and opinions contained in the DBQ. I mention this because some people understandably wonder why it takes me three weeks to complete a report.

I realize that some psychologists conduct six or more C&P exams per day, completing the DBQ while talking with the veteran. If they work a nine-hour day, then they devote only an hour and a half to the exam. I do not understand how a psychologist can conduct an adequate evaluation in 60–90 minutes. According to VA:

A C&P examination for PTSD is particularly complex because an examiner must ... comprehensively diagnose all comorbid mental disorders and apportion disability to various disorders in veterans who increasingly have co-occurring mental disorders; and render an informed opinion about the effects of PTSD on social and occupational functioning, requiring a careful and often time-consuming review of a veteran's history (emphasis added).

Reference: Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39843, 39847 (July 13, 2010).

Many of the fast, cursory exams end up being favorable for the veteran. However, I doubt most such exams are truly evidence-based evaluations that would stand up to peer review, but frankly VA does not have high standards for C&P exams.

Thus, if a subpar exam is favorable to the veteran, it is not the veteran's problem that VA does not place much emphasis on exam quality.

This is one reason I recommend that you get a VA C&P exam first before paying someone like me two thousand dollars for a comprehensive evaluation.

If you get a VA C&P exam first and it goes your way, great. You will not only receive VA disability compensation and other benefits, you will have also saved yourself a couple of thousand dollars for an unnecessary independent exam.

Even though I provide nexus letters for VA claims, I want to conduct an evaluation only if it is necessary and will probably help you.

So, I do conduct IPEs directly for veterans in some cases. For example, if VA (unjustly) denied a previous claim because of a bad exam, or if your claim is uncommon or complex, then an IPE (independent psychological exam) might be worth it.

3. Merriam-Webster.com Legal Dictionary, s.v. “nexus,” September 2023.

4. Principles relating to service connection, 38 C.F.R. § 3.303.

5. Oxford English Dictionary, s.v. “incur, v.”, July 2023.

6. Aggravation of preservice disability, 38 C.F.R. § 3.306.

7. Merriam-Webster.com Legal Dictionary, s.v. “nexus,” September 2023.

8. The term nexus letter sometimes suggests that a healthcare professional can simply review a veteran's records and chat with the vet briefly and then write a letter providing an expert opinion. For psychological claims (PTSD and other mental disorders), providing an expert opinion based on such a cursory review would probably violate ethical principles and professional standards of practice.

9. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008).

10. The "odds of winning your claim exceed 70%" if you have a Veterans Service Officer who has helped you (or you have done your research and really know what you're doing), and if you have solid evidence to support your claim. Seventy percent is an estimate based on my experience.

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