Importance of Medical Evidence & What to Include

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An important part of any case is the medical evidence used to support it.  For VA disability cases, it can be extremely helpful to have statements or evaluation reports from your treating physicians.  When first filing for a claim, the VA must have proof of a nexus. A nexus is a specific, and very necessary, type of medical evidence.  The basis of a nexus statement is to explain the connection between your in-service injury/illness to a current and ongoing disability.  There are five different ways to present a nexus:  direct service connection, service connection through aggravation, presumptive service connection, secondary service connection and service connection for injuries caused by VA health care.

After you have a nexus, you are likely to need additional medical evidence to receive the proper rating for your disability.  Even if you receive a favorable C&P exam report, further medical evidence may be needed because the adjudicator will be the one making a decision and may want more than one favorable opinion prior to issuing a grant.

If you are working with a current treating physician, try to schedule an in-person evaluation for them to include the results in their opinion.  You may also be able to seek a medical opinion from outside physicians based on a review of your records but please obtain current documents for them to have a complete picture of your medical history.  Also, if they are providing an opinion solely based on your records, make sure they mention exactly what was reviewed for their report.

The VA has an online system called My HealtheVet that allows you to keep your records current without the wait time or travel involved to go directly to each facility – especially if you have lived in different areas being seen at various facilities.  In some instances, the medical records alone can be sufficient to show how your disability has affected you over the years and can prove qualification for an increased rating without the need for a formal opinion.  Current medical records can also document a formal diagnosis, as required by the VA, for any newly claimed conditions.

Another reason it is important to have your medical information up to date is that you want the doctor to be able to give a detailed report.  Being detailed doesn’t only refer to listing the specific conditions you suffer from or individual symptoms.  The doctor must provide an answer as to why they are coming to the conclusion provided in their statement or report.

It is not going to be as beneficial if they merely say “unable to work due to medical conditions” or “suffers from back pain.”  You want them to address the specific conditions and exactly why those conditions prevent you from working or how severe your condition is and the resulting limitations.

Since the VA operates under specific regulations and codes, if the doctor is able to use their language in the opinion, it is going to have a better shot at fitting within their standards.  If possible, try to have the doctor include the following terms, as applicable, when stating their opinion:

  • Is due to = 100%
  • More likely than not = greater than 50%
  • At least as likely as not = equal to or greater than 50%
  • Not at least as likely as not = less than 50%
  • Is not due to = 0%

It is important to remember that the opinion does not have to be 100% definitive when commenting on the ability to work or even whether your disability is related to service.  Instead, the VA uses the above standard of “more likely than not”.

Furthermore, you want to try and use a doctor who is board certified in the area of health that is at issue.  While you can, of course, submit a statement from your primary care physician, if you have been referred to a specialist for any of your conditions, see if they may be willing to write an additional statement.  To add to the strength of the doctor’s statement or report, please make an effort to include a copy of their curriculum vitae to show their credentials, allowing the VA to weigh the probative value of the report you provide.

Once you finally have a report that covers follows the general guide, be sure to send a signed and dated copy to the VA but keep a copy for your own records as well.  You may want to send it via certified mail to verify your evidence has been received so if it is not listed as being reviewed, you can notify the VA that you had submitted evidence that was to be considered.  Such opinions can make the world of difference for your case so don’t be afraid to ask your doctor for help.

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