This is a question that we receive, in one form or another, on a regular basis. The issue that arises is that a Veteran will speak to their provider who is willing to provide an independent medical opinion (IMO) relating their claimed condition to service or another service connected condition. The provider will then provide a letter that states “in my medical opinion it is as least as likely as not that (insert a condition here) is related to….” The provider does not offer any further insight for the rationale that their IMO is based upon. The Veteran submits this letter along with their claim and then receives a Rating Decision from the VA denying their claim. The Veteran then wonders why their claim was denied since they submitted a nexus opinion with their claim.
The reasons and basis for the submitted nexus opinion is addressed in the VA’s M21-1. The M21-1 is the VA’s Adjudication Procedures Manual and provides the VA with instructions and procedures on how to determine claims. Within the M21-1 under part V.ii.1.A.3.g, Principles of Reviewing and Weighing Evidence; Medical Evidence; Requirement for Supporting Rationale for Medical Opinions, the VA addresses how medical evidence and medical opinions are weighed and considered in the determination and decision process. On July 1, 2022 the M21-1 part V.ii.1.A.3.g was updated to include the following guidance for the weighing and consideration of medical evidence and opinions:
- Corrects guidance previously published on April 27, 2022, because previously published information communicated an improper evidentiary standard.
- A medical opinion is a conclusion supported by evidence, including current medical literature, information obtained during examinations, the Veteran’s lay statements, and pertinent evidence in the claims folder.
- When reviewing medical opinions, ensure the medical opinion responds to all questions asked in the examination request. Medical reports including opinions must provide a rationale for any opinion rendered. The rationale should cite any general medical principles used to support the opinion; identify pertinent medical evidence and case-specific information relied on to support the opinion, and demonstrate how the opinion was formulated.
- A rationale for a medical opinion should include supportive argument for any opinions rendered or conclusions reached with an analysis that can be considered when weighing contradictory or conflicting opinions. The rationale should provide clear conclusions based upon supporting data and analysis including a reasoned medical explanation connecting the two.
- Adds note: A medical opinion is adequate if it is based on a correct factual premise, and the pertinent medical history and examination is not ambiguous or inconsistent, and provides sufficient detail to fully inform the medical question. Medical reports are to be read as a whole, taking into consideration the history, tests, and examinations upon which the report is based.
The most important takeaway for consideration of nexus opinions is that a nexus opinion must be well grounded with a sound rationale supported by credible evidence, research, and analysis. It is insufficient to simply use the VA’s magic language “it is as likely as not”, without providing supporting rationale.
Additionally, it is important to note that the VA considers not only the evidence in the C-File but also lay statements provided by the Veteran. In a case such as a claim for sleep apnea, the lay statements from others that witnessed symptoms of the condition in service, are often the only evidence of the now diagnosed condition having been present in service. The consideration of these statements is essential to buttress the position of a medical provider’s rationale of how the documented symptoms from the Veteran’s service relate to the now diagnosed condition.
If this information proves useful, but also sounds overwhelming in identifying how to obtain, structure and organize this information, please contact or call the expert VA Claims Lawyers at Gustad Law Group today for a consultation regarding your claim for service-connected compensation from the VA.