I put up the first Nexus Bible in 2011 when I switched over here to WordPress. In the intervening years the VA has changed and now we litigate under the newer Appeals Management Act which began February 19th, 2019. By the mid-2020s the Legacy system will have very few outstanding cases.
With that said, I have begun doing what all modern litigators do and purchasing my nexus letters from a reputable outlet. I personally use Mednick Associates. Another outfit called Medconnect is available but for ethical, proprietary information reasons I decline to use them. I’m sure they are capable at what they do but Momma always said if you can’t say something nice about others, keep your mouth shut. I learned that the hard way when I was sued by Wounded Warrior Project back in 2015.
The essence of any nexus letter or Independent Medical Opinion is simple. VA demands three things of us to satisfy the requirements for obtaining service connection. First, you must have had an injury or disease (or risk factor) in service; second, you must have the same disease or injury or secondary conditions from it now; and third, you need an Independent Medical Opinion (IMO) from a reputable source stating that what you had in service is what you have now or was caused by your service. If you rely on VA to provide you with this “nexus” at your c&p examination, you will find out why you need a truly “independent” doctor to perform the exam. VA-contracted examiners are paid to be independent but somehow 85% of their IMOs are not in your favor. Go figure…
Try this on for size, too. https://asknod.org/2019/03/03/independent-medical-opinions-who-what-where-why-and-when/
With that said, there are what we call presumptives. And boy howdy there are a few of these. The most well-known are the presumptive exposure for Camp LeJeune contaminated water (CLCW) and the Agent Orange herbicide presumptive diseases. We also enjoy the presumption of soundness when we are inducted into the military. In addition, there is the presumption of regularity which doesn’t mean eating Exlax®. Quite simply, the VA operates in a regular manner. If something happens that appears irregular or untoward and you spot it, it means VA cheated, usually. They are prone to do that. Out of giving them the benefit of the doubt, we always presume it was an unintended error and they didn’t mean to.
Direct exposure is another way of proving a claim. If you worked in the motor pool at Camp LeJeune, you would be expected to be exposed to benzene- a common ingredient in both gasoline and the water you were drinking. You can claim exposure on both grounds but again, a doctor has to make this analysis. If you were standing around on the deck of the U.S.S. Minnow watching them bend atoms at Bikini Atoll back in ’48 and have a raging case of the leukemias, yep, that’s a presumptive.
You can always win a direct service connection claim for anything documented in your service department records-like a broken arm or leg. You may not even need a nexus for it. I wouldn’t rush out to buy an IMO until I tried to win on direct.
Who Can Write an IMO?
I have used Doctors, Chiropractors, registered nurses, ARNPs, PA-Cs and any other combo of letters you can come up with. The gold standard is always a doctor. Chiropractors are now respected but they were not in 1989 when I tried it and lost.
There is much controversy about trying to get your own doctor to do this. The first thing you encounter is the word “independent”. Is your doctor giving a truly independent analysis and opinion or is he giving VA what you want him to write? Is he your relative? Your Wife who happens to be an R.N.? See where I’m going with this? If it’s your PA-C brother in law, then the question comes up about whether he knows you. That is an important fact to state. All my IMOs are very particular in stating the doctor has never met my client. I have used a nephew of the client and it was not successful but that was because the guy’s IMO was about two paragraphs long. In combination with about three others, it helped but not as a stand alone product.
When you use your own doctor, he is going to have to state he reviewed you VA claims file. Most doctors I know do not have the time to devote to review 750-2000 pages of your files. If they don’t state they did, VA just says “We read them and his Doctor didn’t so our nexus is more probative because we had all the data. If you see the word “history” used by VA, it means your doctor merely recorded what you told him-your history. VA won’t buy that. You need evidence and good lay statements. Having a doctor merely write what you say happened isn’t going to work unless your STRs show it happened
I include a few IMOs from over the years below to try to illustrate what you need. I still get rejections from VAROs like Little Rock and Jackson, Mississippi but I attribute that to stupidity and a deny-at-all-costs mentality. I always prevail at the BVA with them because they are valid work products and the BVA recognizes it.
The Difference between an IMO and an IME
An IMO has been discussed. An IME is an Independent Medical Evaluation. The BVA will often ask an “independent arbiter” if your IMO is legitimate. It’s the equivalent of an attempt by VA to blow your claim/appeal out of the water. When you get to the BVA on appeal, often the evidence is sketchy. Your IMO is rife with the words possibly and probably. It could honestly be said your claim holds water but is shaky. The Veterans Law Judge in these cases is required to remand it to seek an IME to see if an “independent” doctor might agree or disagree. Yep. 99% are against you. The VA’s idea of an independent reviewer is to go get a hired gun from a VA hospital in Kansas to write an IME about a Vet in North Carolina. Considering who writes the the doctor’s paycheck, it’s almost impossible to get a win this way. Depending on them to be fair is insanity. Thus, we get a truly independent one of our own.
My trick is to file and let VA deny you first. Let them blow hot air about why you are NOT entitled to _____. You can then use your new IMO to specifically address what the VA didn’t. Many times VA simply uses a format and says “Nope. You didn’t have Hepatitis C in service and we don’t see any evidence you suffered anything like it. Denied.” What they know and overlook is that there wasn’t a test for hep C in 1970. Or 1980 or 1990. The first test came online in 1991 and the American Red Cross snapped them all up for a year to protect the blood banks. You were never going to get a test until about 1992 in reality. Further, your liver goes south at a very measured rate so you can measure the degree of deterioration now and extrapolate backwards to find when you were infected. Everyone talks about jetguns but think about what happens now when you go to the dentist compared to the 1968 “Spit that blood into the bowl, Airman.” as they pulled your tooth bare-handed… That was a far greater risk and I’m guessing about 78% of you have your service dental records. Dang-that’s about the only medrecs they managed not to lose.
I see a lot of my fellow Thailand Vets attempt to talk about sticky tools and dead vegetation around the perimeter of the Thai bases we were stationed at. Sorry. All the pictures in the world of dead grass in front of your hootch will not work in court. The same for pictures of guys getting jacked with Jetguns is true. Your pictures will not show the virus on the business end of the nozzle. Saying you stopped at Tan Son Nhut Air Base and deplaned to refuel before continuing to Bangkok has been tried a million times. It helps but you still have to have the Doctor say it.
VA isn’t stupid. As fast as we can come up with ways to defeat their denials, they are busy inventing new ones. You have to stay ahead of their game. Back when Thai Vets began filing for AO shit, VA finally was forced to acknowledge the “tactical herbicides” they used might have been a mite stronger than Roundup™. Now, in spite of what just happened in California where some folks won a big lawsuit over it, it’s still on appeal. You will never get any traction on that. As for Thailand, I’m pretty sure they weren’t using AO strictly. I suspect there was a lot of Agent White and Blue as well. Nevertheless, they are all nasty.
Winning a Thailand claim requires finesse. VA now will allow a presumptive exposure for anyone who was a Security Policeman (AF or Army) or dog handlers. The idea is you have to prove your duties took you into the perimeter areas on a regular basis. The definition of ‘regular’ is debatable. Telephone and cable repairmen get this presumption. I’ve fought a few and won but they are all different. You have to shape the nexus to the Vet. There is no ‘one-size-fits-all’ version.
The worst thing you can say is you worked on Thuds or F4s and they were all “sticky” or had some oily substance on them when they came back from a mission. Get serious. Ranchhand missions which sprayed AO were carefully conducted at about 1,500 to 2,000 feet to avoid too much drift. Fighter pilots don’t get Frag orders taking them into an AO area of operations where spraying is in progress. They don’t do dive bomb passes while dodging C-123s on a spray run over Mu Gia Pass or the Paul Doumer railroad bridge in downtown Hanoi.
You actually harm your claim by making stupid pronouncements about AO. Your win will be because you placed yourself on (or near) the perimeter while taking a smoke break on a regular basis for a year while you were doing airframe repairs on damaged AC-119s and 47s out on the apron or the trim pad at NKP. Even if you claimed there was AO sprayed along the perimeter and you witnessed it, did you stop the spray-rigged deuce and a half and ask the operator what the liquid substance was? Did he actually say “It’s some stinkyass shit called Agent Orange.”? Prove it. Find that guy and have him testify for you 50 years later. See where I’m going? All the buddy letters in the world are worthless unless the Vet says “Johnny and I had to take our smoke breaks across the runway from where we were working on the 123’s and the 130s. The regs said we had to be over 100 yds. away from the A/C. So we’d go over and lean against the perimeter fence and shoot the shit with the Thai sentry over there.” or “We had to walk right down along the perimeter to get to our hootches. They were only about 45 feet away from the front door. The gravel perimeter road we walked on was in between the hootches and the fence.” Shoot. Google a map for your base and try to remember where everything was back then. Throw in you went to “pai teo on Friday/Saturday which entailed walking through…wait for it… the perimeter.
Here’s some examples of winning IMOs I’ve used.
AO in Thailand–Harry Redact AO in Thai
Legal brief for AO in Thailand–Redact VA9 for AO in Thailand
Map Template for bases (Takhli RTAFB)–Takhli titled
Legal brief for AO in Thailand- Filed VA 9 IMO 5-08-2020
For PTSD– PTSD IMO redacted
For Camp LeJeune Water– Camp LeJeune water redacted IMO
For nasal cancer due to AO–AO respiratory IMO redacted
Blindness due to Malaria txment–Malaria IMO redacted
Hepatitis C– HCV IMO redacted
I’ve had a few denied and I send them up on appeal to the BVA. To date, none have been denied. Always remember to make sure your IMO author states s/he has reviewed the VA claims file in writing. This is important. I have seen VA deny based on that alone.
VA uses a gal named Dr. Shirin DaSilva ($137 K/year) out of Nashville/Little Rock to write a lot of their IMOs. She’s worthless but you have to tear apart each one to prove your point. Check this one out.
Filed IMO to BVA 1-8-2018 redacted Dr. DeSilva is the one who mentions polyvinyl chloride which is, as most know, PVC pipe you buy at Home Depot™. I hope all this helps you in your quest for justice.
In the film below, they use jetguns for inoculations. The value of the film is that they do not wipe recruits arms in between injections showing lack of sanitary precautions.
Thank you for all of this invaluable information. Does the physician writing up the IMO have to be licensed in the state that I reside or can they be located out of state? Also, it’s stated in the IMO by the physician that they have had no contact with the claimant. Is it okay to meet with the provider beforehand to give background information or is this not allowed? I can’t seem to find this information anywhere. Thank you so much for your help.
No. The dr. doesn’t need to be accredited in any particular state. There are two different modes of doing this. Now, with the requirements for PTSD/MDD, you need, at a minimum, a face-to-face (video okay) with a psychologist for a first time claim. For increases, it can just be a write up report IMO with no need for personal contact. I am usually the contact go between for Vets and the IMO authors to keep it “clean”.
Dear Asknod, thank you so much for all of the invaluable information contained on your website. I just finished your NEXXUS/IMO section. In it you offer a hypothetical C130 mechanic who spent his daily smoke-breaks leaning against the AO sprayed perimeter fence. This was my husband, exactly, in Thailand in 1969-70. He since has been diagnosed with Parkinson’s Disease. I am (wife) in the process of filing his first VA claim…a daunting task and appreciate all the advice I can get. Again, ThanQ
Well, funny thing you should post this. I just got an IMO back from my IMO factory for my Takhli Vet with Prostate cancer. Look again at the post above. I added his IMO redacted. I filed it the 8th of this month to the BVA as a VA 9. We had to go the old Legacy route as I only had 120 days to get the IMO and write up the brief for filing.
Asknod, thank you for replying so quickly. The IMO that you posted is indeed interesting and has certainly redirected me on a path I would have never considered. I do have a question about the IMO if you don’t mind. The military background and disability/diagnosis sections are lengthy and cited. Did you author and insert these sections as a courtesy for the doctor’s ease or is it imperative that this information be part of the NEXUS letter even if it is redundant?
I provide the IMO doctor with the claims file. He compiles the history and the body of the IMO entirely. If something is wrong or amiss, I ask him/her to correct it. I can have no influence on what the doctor says. An IMO has to reflect that the doctor is familiar with the client and his medical circumstances. That’s what the I in Independent means.
You go Buckwheat! You aren’t just any kind of wheat you are the whole grain!
My HCV claim got remanded and am waiting on results. I could have gotten it several ways and filed them all with the claim. I guess it should be only 1 item such as jet guns but I filed 3 ways I could have gotten it. This is why it got remanded. The judge did ok the transplant so now I will file secondary illness from said transplant. 30% for transplant which should be at least 60%. Waiting for results Ray.
What are the requirements for smc t?
Generally, you need to qualify for a higher level of care as described in §3.352 for symptoms of diagnosed TBI and have served after 9/11/2001. In addition, you need to have a doctor say you would need to be institutionalized if you had no one to provide aid and attendance to you.
I am trying to claim sleep apnea based on my broken nose (Deviated Septum). For the last couple of years I have been denied even with a Nexus letter from the doctor. My VA representative says that the VA thinks that my nose is healed even though I have it in my military records as having a deviated Septum. So now they want me to get the nexus letter to not focus on the broken nose but the deviated septum. Seems like a run around. I need a better Nexus example for the doctor to sign concerning his examination.What do you think?
You need an atty. to get you a good nexus letter that will win. VA will never give you one.
Does anyone have a nexus letter i can leverage to get the right information?
You should hire asknod@gmail. He is the hardest working, results oriented law dog I know. I got mine by taking a sleep study that my doctor recommend I take. Sent the results to the VBA and they ok’d it. I hope the best for you. Welcome home.
he can be reached at this link. Scroll to the bottom of the page as you will see his e mail and phone#. I would hire him ….He is very good at what he does…https://asknod.org/about/
(253) 313-5377 Hire this guy Vaughn Camper.
Vaughn, Search this site and you’ll eventually run into a nexus letter in one of my blogs…if you search and read them. Here’s one that has a good nexus letter /IMO example of what is needed to win. https://asknod.org/2018/03/22/bva-two-american-kids-growing-up-in-the-heartland/. Scroll down to Medders BVA intro of new evidence redacted. There’s a lot to be learned here. It represents 11 years of fighting the VA and how to do it. In this day and age, everyone seems to want the quick fix and have it instantly regurgitated onto a copy and paste format. VA law is far more complicated as are each and every Veteran’s claim(s).
Thank You for providing me a view of the document. I see what you mean by having some with a law background to write the nexus letter. I did have a sleep study and got the doctor to sign a nexus letter stating the standard information for someone with a deviated septum. I would like to share that with you and let you see how far off I am. That was a lot of detail.
I’m really confused about this hepatitis thing. I’m a Vietnam vet. Retired in 1990. Filed first VA claim in March 2010 (8 items, 3 were service connected). Hepatitis was one item that was denied. I didn’t know which flavor; A, B, or C I had. The symptoms came on me the same time I got back to the US during late Nov/early Dec 1972. Diagnosed as Hep A in early 1973 (January). Based on what I’ve read on your blog, how could it have been Hep A like the VA has stated? Any way you could look at my rating decision and determine if the VA screwed up? I haven’t had any symptoms since but I’d still like to know if I have a possible case. Thanks for any advice/assistance you can render.
contact me at email@example.com and scan/attach the rating decision. I’m an Officer of the Court now so you do not have to redact the SSN. Relax. I have plenty of condos in Puerto Vallarta and don’t need any more.
Will do thanks again and I will touch bases with you in Sept.
I’ll have my gastro doc write it up. He should know also
Thank you for the feedback. The RO has denied my claim for hep-a because it resolved itself in 20 days in the hospital. I have been vaccinated for Hep-A and B . Will the test still work? It’s on appeal to the BVA. thanx again
Can you tell me what acute viral hep means. The Doc wrote HAA weakly positive….sorry I know I am a pain but am trying to clear this up before the hearing. Thanx Alex RAY
HAA means Hepatitis Australia Antigens test. If it was weakly positive, you had acute viral hep or HBV. That might indicate you had Hepatitis B. I have also heard doctors state some patients had the same thing (positive HAA) with a HCV diagnosis later on when they could test for it after 1992. If you had Hepatitis A (HAV), the HAA test would never be positive. More importantly, they now have a specific test that can spot the presence of HAV in your blood if you ever had it. Once you get HAV, your body develops a cure for it and leaves the antibodies in your blood forever. You can never get HAV again. Most develop the same antibodies and resistance to HBV as well. The mere presence of a HAA positive test means HBV but not HAV. One of our HCVets, Malcolm Melancon, had a positive HAA test in 1990 and lost his claim. Later, in 2001, he was diagnosed with HCV but the HAA test came back negative. In other words, he never had HBV-ever.
thank you bro
Alex, Help me with this. I had a serology test which showed HB Ag negative and negative antibody to hep A and positive antibody hep C. Can you tell me what this means. This was done 1995 by gastroenterologist. Thanx Ray Can you represent vets for VA claims yet? If so I would like to hire you.
An HB ag test doesn’t exist. Perhaps you mean HBSAg which is the Australian Antigens test. Hep B Surface antigen tells you if you have ever had Hep B. Apparently, you nave not. Similarly, a negative antibody reading for Hep A would indicate you have never had HAV either. As for representing you for claims, yes I can but it will be a short while before I can do so. I’m overbooked now and do not want to turn into one of those VSO pukes who never return their calls or help Vets win. Constact me @ firstname.lastname@example.org in September and we’ll talk then. Thanks
See you then Mr.
Alex, the HAA test is what blood banks use to test blood donations for hep B. Depending what test they used it may be a FALSE POSITIVE.
Thanks for that. Can I find a link for this for evidence to Janesville? I have researched Hep_ A and found that it was not identified until 12/73. I had it 1/73. The Dr. called it acute viral hepetitis . Discovered by Steven Fienstone 1973
One thing modern science is good for is knowing what you’ve ever had in your life. If you have had HAV, you develop an antibody to it. Same for HBV. A simple blood test will show what you have had in the past. The Australian Antigens test was the defining test in 1970 or so to show the difference. If the test was positive, you had HBV. If it was negative, you had HAV. HCV often traveled with HBV because they are both blood-borne diseases. HAV comes from contaminated food via the oral route (meaning you ate it). Viral hep was HBV. Infectious Hep was HAV.
On my blood test 1995 from Gastro doc he states Hep-A antigen is negative.. The RO denied my claim because They said I recovered from this Hep=A virus. Are they wrong? Thanks again They also said deny because I have tattoo That was put on when I was 15 with a sewing needle. It was a new needle
Again thanking Alex the nod man. I am playing the waiting game attorney said 2 to 4 years to BVA on vacation to the beach. Oregon beach ….happy trails brother
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Thank you again…so now if I get evidence for my hep-c I mail it to janes ville? Or to the lawyers?
Always to the law dogs. They are driving your claim boat.
I got my C-File on disc and made a discovery ….I had hep-A in 1973 and through my research they hadn’t discovered hep-a until Dec. 1973….I got it in Jan 1973…I think this was Hep-C and they just put A .How could they know it was Hep-A if it hadn’t been discovered yet? Ray
Hep A-or infectious Hep. lasted about 5-10 days. Hep B (viral) lasted about 6 weeks and wiped you out. If you were in the boonies, they didn’t have the Australian Antigens test to figure it out. They just kept you hospitalized until your eyes weren’t yellow anymore.
I had hep-a ft.hood when I came home from Nam….It wiped me out never been that sick in my life ..hep-a was discovered in 73 that’s when I got it. I am sending the disc to dr. cecil
I was hospitalized for 5 weeks ….rash yellow stool white ab pain vomit can this be hep-a?
No sir. That was undoubtedly Hep B. HAV would only put you down for a week or 10 days.
cool….They (VA) made an appointment for me to see a private shrink here in wenatchee. Will they give me the prognosis on paper …can I get it from them?
Well, not exactly as they say a dollar a day rentacar. VA ordered it so it will be a VA-purchased nexus. It could be done by the QTC outfit VA uses a lot. As such, it’s slightly better than one from the Medical Lake shrinks. If they deny you, it still pays to have a backup plan before you go to the BVA.
The bent brain nexus can only be done by VA doctors or Private doc.?
Correct. But that doesn’t prevent you from getting your own and submitting it as evidence. Just make sure to get your Service records to show him/her.
What I meant was a private doctors word will override the VA doctors word ?
No, but a private doctor’s word can never be ignored. By having a private mental nexus letter, VA will always have to deal with it. Often it can help to win when they see you have additional ammo.
Absolutely Brilliant work, Asknod…! God bless you brother for helping so many of us Vets…!
Having spent 26 years chasing my claims, I finally decided to teach others the fine points. Thank you and I hope I pass the audition.
As always brilliant information! Thanks Alex for taking the time. You r an outstanding solider/veteran. Salute! 😎🙏🏾
How can I get a copy of this book!
I bought your book. In fact both the Kindle version and the hard copy. I have also had some advice from you about my claim. (I kind of hope you saved some of the letters I sent to you.)I have a doctors appointment this Thursday with a new back specialist and a BVA visiting judge hering on the 14 th of October. I intend to try and get the previous doctors nexus letters substantiated by this new back doctor. I am going to ask him to concur with the other two doctors that wrote letters but again, did not use the correct phraseology.
I decided to switch doctors because of the comments the Ph assistant made about the professor of spine surgery who did not use the correct phraseology in his nexus letter and was severely talked down on by the comp examiner. In his review. ( Isent you a copy) of the comp exam c file copy and the doctors letter.
I need a back pertinent nexus letter. I can’t seem to take your hepatitis letter apart to apply to the back. Can you help? Before this Thursday so I can ask and maybe get it signed.
Also if you still have any of my attachments or need any I can oblige if you do I would like any advice on what to put emphasis on at the hearing which is all about Service connection.
Historically everyone should know about the honesty of the Department of Veterans Affairs. As a agency before VRJA of 1979? Back during the 1920s, or so the first VA Administrator Mr. (Col.) Charles R. Forbes was prosecuted and sent to Fort Leavenworth for a little over two years prison time for VA Fraud. Source Wiki. He is also buried at Arlington while not to take away from his WWI military service.This is why some choose to leave via the back door at the end of the day to their private parking spot under armed guard and insulate themselves from email, letters and telephone calls.