Why a “Better” Nexus Letter Still Lost to a Two-Sentence C&P Opinion

Everyone said that the missing piece was a nexus letter. So, you paid for one.

It was a positive opinion in support of your claim. It used the magic phrase: “at least as likely as not.” It was long, filled with research, and looked much better than the C&P examiner's two-sentence negative opinion.

But the VA still denied your claim with this explanation:

“While you submitted positive medical evidence to support your claim, we found other medical evidence more persuasive because it is better supported in its rationale and conclusions.”

How does that make sense? And where do you go from here?

Let's look at some of the questions that might be going through your head right now.

Doesn't the Tie Go to the Veteran?

If there was one positive opinion and one negative opinion, doesn’t that mean the tie goes to the veteran? Isn’t that the benefit of the doubt rule?

This can be confusing. In a vote, if the same number of hands go up on each side, you have a tie. So, one yes and one no seems like a tie. It looks like the evidence is in equipoise.

But medical opinions aren't votes. Each one doesn't count the same as another.

Adjudicators have to determine the probative value, or weight, of the evidence in a claim. That is based on things like the examiner’s relevant expertise and the accuracy and adequacy of the reasoning behind their opinion.

In other words, the VA doesn’t count medical opinions. It weighs them.

Yes, the tie goes to the veteran, but one positive opinion and one negative opinion isn’t automatically a tie. That depends on the probative value of each of those opinions.

How Could a Two-Sentence Opinion Beat an Eight-Page Nexus Letter?

This question came up in a case I recently reviewed.

The veteran was claiming that their obstructive sleep apnea (OSA) was proximately due to or the result of their service-connected major depressive disorder (MDD).

The positive opinion came from a private examiner. The nexus letter was eight pages long.  And it didn’t just list numerous medical literature references in support of the claim, it explained how each one supported the claim.

The negative opinion was from the C&P (Compensation & Pension) examiner. It was only a few sentences long, with no literature references at all.

The VA denied the claim, saying it had given greater probative weight to the negative C&P opinion.

I’ll admit it. At first glance, this looked like BS.

The C&P examiner’s opinion didn’t offer some amazing rationale. And, it wasn’t just that it didn’t offer any citations, it specifically said that there wasn’t any supporting research, even though the private nexus letter cited several examples of supporting research.

On the other hand, the private nexus letter appeared professional and sophisticated. And it was loaded with research articles.

Then, I started looking up each of the articles it referenced, one by one.

Some of them didn't match their descriptions in the nexus letter. Others suggested that OSA may contribute to depression, but this claim wasn’t about depression secondary to OSA.  It was for OSA secondary to depression. The research went in the opposite direction.

Citations don't make an opinion more persuasive if they don't actually support the conclusion.

On top of that, the nexus letter never tied any of the literature back to this veteran's own history. What facts supported that direction of causation? How did the timing and clinical course fit? What other medically significant factors were considered?

Even with valid, accurate medical literature, a nexus letter needs to apply that reasoning to your specific case. This one didn't.

It turned out that the positive nexus letter was not nearly as persuasive as it looked.

A positive nexus letter is not persuasive just because it reaches a favorable conclusion, uses the right language, or includes a long list of research citations. What matters is whether the reasoning is accurate, whether the evidence actually supports it, and whether that reasoning is applied to your specific history.

What Does This Denial Actually Mean?

A denial like this tells you that the adjudicator looked at the evidence on both sides and decided the evidence against your claim carried more weight. That does not automatically mean the negative opinion was right. It may simply mean that the positive nexus letter did not do a good enough job of supporting its conclusion.

There is a difference between:

• “This positive opinion was not persuasive enough to establish the nexus,” and
• “The facts of this case do not support a positive medical opinion.”

The denial tells you which evidence the adjudicator found more persuasive. It doesn't independently answer the underlying medical question.

How Do You Know What Was Wrong with Your Claim?

Unfortunately, the denial itself may not tell you.

Maybe the connection you're claiming is medically supportable, but the nexus letter explained it poorly. Maybe important evidence was never submitted or wasn’t adequately addressed.

It is also possible that the actual facts of your case – the timing, your medical history, and what happened before and after the condition developed – don’t meet the criteria for service connection.

Figuring out what actually happened means digging into:

• The reasoning in both opinions
• The medical literature each opinion relied on
• The timeline in your records
• The other facts that could support – or contradict – the claimed connection

There are limits to how much of this you can realistically assess on your own. You can see that a nexus letter is eight pages long, cites a lot of research, and gives you a positive opinion. What you might not know is whether those studies actually say what the writer claims they say, whether they apply to your situation, or whether the medical reasoning leaves out something important.

That’s what makes this kind of denial especially frustrating. You relied on an expert to understand the medical literature and put the pieces together correctly – and this time, that trust didn’t pay off.

Should You Pay for Another Nexus Letter?

Don’t assume that the answer is simply to get another nexus letter.

Before you spend more money, you need a better understanding of what the VA found unpersuasive about the evidence you already submitted and what questions still need to be answered.

If you are not already working with a VSO, this is a good time to start. A knowledgeable VSO can help you understand the decision, what review options are available, and whether additional evidence may be useful. They likely can’t tell you whether a particular medical theory is clinically supportable, but they can help you make sense of where your claim stands before you pay for more medical evidence.

If the remaining question really is medical, though, you may need someone with the right expertise to evaluate what’s already been done.

Yes, I recognize the problem with that advice – you already trusted and paid one expert without any benefit, and now you are being asked to trust another expert to do what the first one didn’t.

Before you pay for another opinion, the first question should be whether the medical evidence actually supports a positive opinion at all, and what the evidence already submitted does – and doesn’t – establish.

That is one reason I use a phased approach for claims like this. I do not want the first step to be, “Pay me to write another nexus letter.” The first step is to review the existing opinions, the relevant records, and the medical literature and determine whether the reasoning actually holds up.

I can’t guarantee how the VA will decide your claim. What I can do is give you an honest assessment of whether the facts support moving forward, what additional evidence may still be needed, and whether another opinion might actually add something useful.

At this point, the goal isn’t just to find someone else who will write a nexus letter. It’s to understand whether a positive medical opinion can actually be supported – and, if it can, what evidence and reasoning are needed to support it properly.

Denied despite a strong-looking nexus letter?

Before you pay for another opinion, it helps to know where you stand. To figure out your next steps, learn more about the denial scenario that best matches your situation.