VA Nexus Letter for PTSD. VA will pay disability compensation to a veteran if he proves his disability is related to military service. As part of the process, VA uses disability nexus letters to figure out whether a disability was caused or aggravated during service. If the answer is “No”, then VA will not pay for that disability.
Will You Need a VA Medical Nexus Letter for PTSD?
Not every VA claim needs a nexus letter because in some cases, the link to service is undeniable. For example, if your service records include a diagnosed disability you still suffer from today, then VA would probably grant a claim for that disability without a nexus letter. In claims for certain chronic conditions, VA will concede a relationship to service if there is a diagnosis within 1 year of discharge.
However, what if you don’t have a diagnosis until many years after service? For example, Vietnam veterans with Agent Orange exposure usually don’t develop herbicide-related disabilities (such as diabetes mellitus type II) for several years. The gap from discharge to diagnosis can be even greater with mental health disorders. Many veterans respond to traumatic in-service events by trying to cope on their own. Coping mechanisms include self-medication with drugs or alcohol, avoidance of medical treatment, and withdrawal from social situations. When the symptoms get much worse and they finally seek mental health treatment, a doctor renders a diagnosis of PTSD. To win this kind of claim, a strong disability nexus letter for PTSD is essential.
Who should Write Your VA Nexus Letter for PTSD?
Only a medical professional with the appropriate medical training should write a disability nexus letter. In limited circumstances, non-doctors such as physician’s assistants and nurse practitioners can write them. However, VA will find a disability nexus letter more persuasive if written by a doctor in the relevant specialty. For mental health disorders such as PTSD, a psychologist or psychiatrist would be ideal.
From time to time, VA will ask affiliated doctors to write disability nexus letters. However, most of those are not favorable to the veteran. Give yourself the best chance to win by seeking an independent disability nexus letter. If applicable, you should have your treating doctor write one. That doctor is probably more knowledgeable about your condition than any of VA’s hired guns.
Requirements for a VA Nexus Letter for PTSD
VA will only accept a disability nexus letter if it meets certain requirements. A strong disability nexus letter for PTSD must include:
A discussion of relevant medical history from
service to the present day,
The likelihood that the PTSD was caused or
aggravated during service, and
A reasoned explanation for the conclusion.
Medical History
The medical history from service to the present day is especially relevant to what caused PTSD. Even the PTSD diagnosis happens years after service, the onset of the disability can be shown in service records. Let’s say a veteran claims that racial harassment during service caused a persistent PTSD disability. The service medical records don’t show treatment for PTSD. However, the personnel records showed a drastic change in behavior 5 months prior to discharge. His first 5 years of service included multiple commendations for performance. In the last 5 months, he received multiple Article 15 punishments. A good disability nexus letter would consider whether the sudden behavioral change marked the onset of PTSD.
How likely is PTSD related to service?
The burden is on the veteran to prove his claim. However, the standard of proof is much lower than in a criminal case. The doctor who writes the nexus letter does not have to be 100% sure of the link. Because this is a veteran-friendly system, VA requires at least 50% certainty. If your doctor finds there is at least a 50/50 chance that your PTSD is related to service, then that is enough to win. In other words, a good disability nexus letter states that it is “at least as likely as not” that the disability is related to service. A strong nexus letter would express “more likely than not” certainty.
A doctor is more likely to write a good disability nexus letter if PTSD clearly existed from service to the present day. You can improve your odds by giving your doctor any of the following:
Your full service medical and personnel records,
Lay statements from friends and family who
observed your behavior from service to the present day, or
Post-service medical and/or arrest records
relevant to PTSD.
What is the doctor’s reasoning?
In a disability nexus letter for PTSD, 80% of the value comes from the doctor’s reasoning. If the letter only contains data and conclusions, then it won’t help the case. At a minimum, the reasoning must be clear, concise and supported by valid medical analysis.
For example, let’s say you are seeking a medical nexus letter for PTSD. After reviewing your medical history, your psychologist agrees that “it is at least as likely as not that” your PTSD was incurred during your military service. Her medical nexus letter should explain why the in-service symptoms and the post-service diagnosis matters. It should also cite any medical literature that supports her opinion. If there was any post-service trauma, she should explain how it only made the existing PTSD worse.
What is a VA Disability Nexus Letter for PTSD? If you’re reading this, then you are probably familiar with the basics of a VA disability claim. Before we discuss what a medical nexus letter is lets review the basics. To win a VA disability claim, the veteran must prove all required elements of that specific claim. In general, VA will only grant your claim if you prove these 3 elements:
Current diagnosis of a disability,
In-service event, disease or injury, and
Medical nexus between the first 2 elements.
A veteran’s doctor can provide a current diagnosis. Either service records or witness statements can prove the in-service event. The medical nexus requirement is often the most challenging element to prove.
What is a VA Disability Medical Nexus Letter for PTSD?
A good medical nexus letter can be the difference between winning your PTSD claim and losing it. However, it is not enough for a doctor to state that the current diagnosis is related to the in-service event. Unless the letter meets certain requirements, VA will not accept it as evidence. A strong medical nexus letter should:
Be written by a qualified medical professional,
Be based on the veteran’s medical history both
during and after service,
Include an opinion on the likelihood that the
veteran’s disability was caused or aggravated by the in-service event, and
Include an explanation for the opinion that is
easy to understand.
VA Disability Nexus Letter for PTSD: Qualified medical professional
As the term suggests, only a medical professional can provide a medical nexus letter. This means that a veteran should only seek this from someone with the appropriate medical training. In limited circumstances, non-doctors such as physician’s assistants and nurse practitioners can write medical nexus letters. However, keep in mind that VA may get a competing nexus letter from someone more qualified than a nurse practitioner.
In all cases, a veteran should seek the most competent medical professional for this important task. For example, if you need a medical nexus letter for PTSD, then you should probably consult a mental health professional like a psychologist or psychiatrist. A PTSD nexus letter from an orthopedist probably would not help your case. Choose your author wisely, and make sure the letter includes his/her qualifications and contact information.
VA Disability Nexus Letter for PTSD: Medical history provides context
When it comes to what caused a disability, context is everything. If the medical professional doesn’t know the service and post-service medical history, then how can he tell what caused the disability? This requirement helps VA avoid paying veterans for disabilities unrelated to service. Let’s say a veteran is seeking a medical nexus letter for PTSD and PTSD. He tells his doctor that the PTSD must have been related to racial discrimination he suffered in service, and the PTSD followed soon after. However, his medical records show there was no PTSD diagnosis until he was involved in a fatal car accident 12 years after discharge. If the doctor writes a medical nexus letter without this context, then VA would probably reject it outright.
VA Disability Nexus Letter for PTSD: What if the doctor is not 100% sure?
While the burden is on the veteran to prove his claim, the standard of proof is much lower than in criminal or civil cases. A VA disability nexus letter for PTSD does not need to express 100% certainty. It does not even need to be beyond a reasonable doubt. If your doctor finds there is at least a 50/50 chance that your disability is related to service, then that is enough to win. In other words, a good medical nexus letter states that it is “at least as likely as not” that the disability is related to service. Of course, if your doctor believes it is more likely than not, then this only strengthens the nexus letter. The more context a veteran provides, the more certain a doctor can be of the relationship to service.
VA Disability Nexus Letter for PTSD: How did you get to your conclusion?
Most of the value of a medical nexus letter comes from its reasoning. If it only contains data and conclusions, then VA will reject it. A nexus letter that merely lists the evidence reviewed without explaining why it led to the conclusion has no value. At a minimum, the explanation must allow VA to conclude that the doctor applied valid medical analysis to the facts pf the case.
Example of a VA Disability Nexus Letter for PTSD
Let’s say you are seeking a medical nexus letter for PTSD. For the past 5 years, you’ve seen a psychiatrist for regular treatment. After the doctor agrees to help, you give him full access to your military and civilian medical records. During his review, the doctor notes that you had in-service medical treatment for symptoms of PTSD. The doctor also notes that the PTSD was diagnosed less than 2 years after service. After reviewing medical literature, the doctor agrees that “it is at least as likely as not that” your PTSD is related to your military service. His medical nexus letter should explain why the in-service symptoms and the post-service diagnosis matters. It should also cite any medical literature that supports his opinion. This would be a very strong medical nexus letter for PTSD.
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VA Disability Sleep Apnea Eligibility Criteria. The VA uses sleep apnea eligibility criteria to figure out the correct rating for a veteran’s disability. That goes for sleep apnea, PTSD, and any other disability. But before VA will assign a rating, it must first determine whether the disability is related to service. In other words, VA must first grant service connection before it will assign a rating.
Generally, VA will grant service connection if the veteran can show:
a current diagnosis,
an in-service event, disease or injury, and
a medical connection between 1 and 2.
Schedule of Ratings for VA Sleep Apnea Eligibility
The Schedule of Ratings breaks down disabilities into different categories. Each category contains groups of medical problems. For example, Sleep Apnea is found in the Respiratory System category. Each group contains a list of disabilities, and each disability has its own diagnostic code. In turn, each diagnostic code specifies the symptoms required for various ratings. For example, the 6847 code applies to Sleep Apnea. Depending on the symptoms, VA will grant either a 0%, 30%, 50% or 100% rating for sleep apnea.
The VA sleep apnea eligibility criteria:
100%: Chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires tracheostomy;
50%: Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine;
30%: Persistent day-time hypersomnolence; and
0%: Asymptomatic but with documented sleep disorder breathing.
To Prove Sleep Apnea you Need Medical Evidence
Only medical evidence can satisfy the eligibility criteria for these ratings. It is not enough for the veteran to say “I meet the criteria for a 50% rating.” Fortunately, VA’s website provides rating tools such as Disability Benefits Questionnaires (DBQs). Specifically, VA provides a Sleep Apnea DBQ that focuses on the symptoms described in the Schedule. Veterans seeking a higher rating for sleep apnea should have their doctors complete the DBQ. If the criteria for a 100% rating for Sleep Apnea is noted on the DBQ, then VA will likely grant that rating.
Most Veterans with VA Connected Sleep Apnea are Eligible for 50% Rating
Most veterans with sleep apnea meet the eligibility criteria for a 50% rating. The VA Health Care system often prescribes CPAP machines to treat severe cases of sleep apnea. If you get your sleep apnea treatment at a local VA hospital, then your doctor has probably considered a CPAP machine.
VA Sleep Apnea Eligibility, 100% Rating
A small percentage of veterans meet the eligibility criteria for a 100% rating. This is because it reflects the most life-threatening versions of sleep apnea. Chronic respiratory failure usually happens when the airways that carry air to your lungs become narrow and damaged. In other words, less oxygen gets in and less carbon dioxide goes out. A tracheostomy is a surgically made hole that goes through the front of your neck into your windpipe. A breathing tube is placed through the hole and directly into your windpipe to help you breathe. Naturally, a veteran with these extreme symptoms deserves a 100% VA rating for Sleep Apnea.
Sleep Apnea Pyramiding
Under the VA rating system, a veteran should be compensated for each service-connected disability. However, there is one big exception. VA cannot pay a veteran more than once for the same disability or same manifestation. This is considered pyramiding, and it is strictly prohibited. For example, Asthma and Sleep Apnea have nearly identical manifestations. They both involve impairment of the airways, they share symptoms such as daytime fatigue, and they are under the same category in the Schedule of Ratings. A veteran who meets the eligibility criteria for both will only receive a rating for one of them. In that circumstance, VA must assign the higher of the 2 possible ratings.
Sleep Apnea Anti-Pyramiding Rule
The anti-pyramiding rule recently affected a DHG client. He is a 64 year-old veteran of the Army who filed a claim for asthma and sleep apnea. VA denied the sleep apnea claim, but granted the asthma claim at 30%. After a successful appeal, VA granted 60% for his asthma. In the new decision, VA conceded that his sleep apnea was service-connected and would meet the eligibility criteria for a 50% rating. However, VA could not grant the additional 50% rating because of the anti-pyramiding rule. Instead, VA awarded 60% for his “asthma with sleep apnea.”
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National Heart, Lung and Blood Institute: “Tracheostomy”
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Can I get TDIU for PTSD? Yes. TDIU is a special benefit for veterans who cannot support themselves due to service-connected disabilities. It pays the same as a 100% rated disability. For TDIU to apply, your PTSD must first be service-connected. This may seem simple, but several veterans have PTSD because of a traumatic event that happened years after military service. Second, you cannot earn a living because of PTSD.
TDIU for PTSD Requirements
In order to be granted TDIU for PTSD is does not mean the veteran has to be unemployed. VA will grant TDIU to an employed veteran if the employment is considered marginal. VA deems employment marginal if the veteran earns LESS than the federal poverty threshold for one person (in 2018, $12,784.00 per the U.S. Census Bureau).
Rating Percentage
The veteran must meet the percentage requirements. If the veteran has only one service-connected disability, it must be rated 60% or higher. The Schedule of Ratings for PTSD permits only the following ratings: 0%, 10%, 30%, 50%, 70% and 100%.
Services Connected Disabilities
If the veteran is only service-connected for PTSD, it must be rated no lower than 70% to get TDIU. However, if the veteran has more than one service-connected disability, then at least one must be rated 40% or higher. Also, there must be “sufficient additional disability to bring the combined rating” to 70% or higher.
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Disability Help Group Case Studies
Case Study 1: TDIU for PTSD
A 60 year-old veteran was diagnosed with PTSD secondary to his service-connected hypertension. VA previously awarded 10% for his hypertension. In March 2018, the Board of Veterans’ Appeals denied his PTSD claim. After a successful appeal, DHG secured a remand for a new VA medical examination. In November 2019, VA granted service connection for PTSD at 70% effective September 2009. Because the evidence showed that his PTSD prevented him from working, VA also granted entitlement to TDIU. He received a lump sum of $340,000.00, and his monthly payment changed from $133.57 to $3,057.13.
Case Study 2: TDIU for PTSD
A 65 year-old veteran asked VA for a higher rating for his PTSD. At the time, he was service-connected for tension headaches at 50% and PTSD at 50%. His combined rating was 80% and he had not worked since 2012. After a successful appeal, VA granted TDIU back to 2012. As a result, he received a lump sum of $121,000.00, and his monthly payment changed from $1,556.13 to $3,057.13.
Case Study 3: TDIU for PTSD
A 65 year-old veteran had a 50% rating for anxiety with PTSD and a 10% rating for a lumbar spine condition. Shortly after he hired Disability Help Group, it was clear that VA should have granted at least a 70% rating for anxiety with PTSD. After a successful appeal, VA granted a 70% rating for PTSD and then granted TDIU. He received a lump sum of $109,000.00, and his monthly payment changed from $1,062.27 to $3,057.13.
While most of this article refers to PTSD, it also applies to other mental disorders. For example, many of our clients have won TDIU based on their service-connected schizophrenia.
Before VA will award a disability rating for post-traumatic stress disorder (PTSD), the veteran must first prove service connection. Thereafter, the VA must determine the correct rating percentage, which will determine how much money VA must pay to the veteran. Rather than assign percentages at random, VA uses a Schedule of Ratings.
Schedule of Ratings: VA Disability Rating for PTSD
The Schedule of Ratings breaks down disabilities into different categories. Firstly, each category contains groups of medical problems. Secondly, each group contains a list of disabilities, and each disability has its own diagnostic code. Thirdly, every diagnostic code specifies the symptoms required for various ratings. For example, the 9411 code applies to PTSD. VA rates PTSD –along with 36 other mental health conditions – under the General Rating Formula for Mental Disorders. Depending on the symptoms, a veteran may receive either 0%, 10%, 30%, 50%, 70% or 100%.
The Criteria: VA Disability Rating for PTSD
100% = Total occupational and social impairment
gross impairment in thought processes or communication;
persistent delusions or hallucinations;
grossly inappropriate behavior;
persistent danger of hurting self or others;
intermittent inability to perform activities of daily living, such as maintenance of minimal personal hygiene;
disorientation to time or place;
memory loss for names of close relatives, own occupation, or own name
70% = Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood
suicidal ideation;
obsessional rituals which interfere with routine activities;
speech intermittently illogical, obscure, or irrelevant;
near-continuous panic or depression affecting the ability to function independently, appropriately and effectively;
impaired impulse control (such as unprovoked irritability with periods of violence);
spatial disorientation;
neglect of personal appearance and hygiene;
difficulty in adapting to stressful circumstances, such as work or a work-like setting;
inability to establish and maintain effective relationships.
50% = Occupational and social impairment with reduced reliability and productivity
flattened affect;
circumstantial, circumlocutory, or stereotyped speech;
panic attacks more than once a week;
difficulty in understanding complex commands;
impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks);
impaired judgment;
impaired abstract thinking;
disturbances of motivation and mood;
difficulty in establishing and maintaining effective work and social relationships.
30%= Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks
depressed mood;
anxiety;
suspiciousness;
panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).
10% = Occupational and social impairment due to mild or transient symptoms
decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or
symptoms controlled by continuous medication.
0% = A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.
100% VA Disability Rating for PTSD
A 100% disability rating for PTSD reflects total impairment. Symptoms in the 100% range include persistent suicide attempts. However, a veteran with very mild PTSD controlled by medication will probably receive 10%. VA is bound by the Schedule of Ratings. Especially, if your service-connected disability satisfies the criteria for a higher rating, then VA must grant that rating.
Case Studies: VA Disability Rating for PTSD
To meet the criteria for a specific PTSD rating, the veteran’s symptoms must approximately match the listed criteria. The following examples show how VA assigns disability ratings for PTSD:
Case Study 1: 100% Rating for PTSD
A 35 year-old unemployed veteran with PTSD attended a VA medical exam. The examiner noted the following PTSD symptoms: frequent thoughts of suicide, impairment of short- and long-term memory, impaired impulse control, persistent delusions and hallucinations. In addition, the examiner noted total occupational and social impairment. Because the veteran had several symptoms in the 50%-70% range, the combined effect rendered him totally impaired. As a result, VA awarded the veteran a 100% rating.
Case Study 2: 50% Rating for PTSD
A 63 year-old veteran with PTSD rated at 10% provided a Disability Benefits Questionnaire (DBQ) from his doctor. The DBQ noted depressed mood, flattened affect, panic attacks twice a week, impaired judgment and difficulty in establishing effective relationships. In the end, VA increased his PTSD disability rating to 50%.
Case Study: 10% Rating PTSD
VA rated a 44 year-old veteran at 10% because her PTSD symptoms were well controlled with medication. She asked VA to increase the rating to 30% because she had 2 panic attacks in the past 12 months. The panic attacks happened during her commute to her full-time job. The attacks resolved within minutes, and she did not lose any time from work. In brief, VA kept her PTSD disability rating at 10%.
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