Provider Selection Strategy

For most secondary claims, a combination of providers yields the strongest evidence:

1. VA providers for ongoing treatment and documentation of both primary and secondary conditions
2. Private specialists for diagnostic confirmation and nexus opinions
3. Primary care providers for documentation of how conditions interact and affect overall health
4. Independent medical examiners for complex cases or appeals after denial

This multi-provider approach creates a comprehensive medical record that addresses all aspects of your secondary claim.

Sample Provider Conversation

Veteran: “Dr. Johnson, I’m here today not just for treatment but also because I need your help with my VA disability claim. I’m service-connected for diabetes, and I believe the peripheral neuropathy you’ve diagnosed is secondary to my diabetes. Could we discuss this relationship?”

Provider: “Yes, we can discuss that. Peripheral neuropathy is certainly a common complication of diabetes.”

Veteran: “That’s helpful to know. For my VA claim, I need to show that it’s ‘at least as likely as not’ that my diabetes caused or aggravated my neuropathy. Based on your experience and my case, would you say that standard is met?”

Provider: “In your case, given the pattern of symptoms and their progression after your diabetes diagnosis, I would say it’s more likely than not that your diabetes has caused your peripheral neuropathy.”

Veteran: “Thank you. Would you be willing to document that opinion in my medical record today and possibly provide a brief letter stating this connection for my VA claim? I’ve brought a draft letter that covers the points VA needs addressed, which you can modify as you see fit.”

Provider: “I can certainly document this in your medical record today. Let me see the letter you’ve drafted. I may need to make some modifications based on my professional assessment, but I’d be willing to provide something along these lines.”

Veteran: “I appreciate that. The VA specifically needs you to address whether my diabetes caused or permanently aggravated my neuropathy, and to explain the medical reasoning. Would you be comfortable providing that explanation?”

Provider: “Yes, I can explain the mechanism by which diabetes affects the peripheral nerves and relate that to your specific symptoms and test results. I’ll note that in your record and include it in the letter.”

Veteran: “Thank you. Is there any additional testing you’d recommend that might further document this connection for my claim?”

Provider: “An EMG/NCS test would provide objective evidence of the neuropathy and its pattern, which could help confirm it’s consistent with diabetic neuropathy. Let’s order that test.”

Veteran: “That sounds helpful. One last question – would you be willing to review these medical journal articles I’ve brought that discuss the relationship between diabetes and neuropathy? They might be useful references for your letter.”

Provider: “I can take a look at them, though I’m familiar with the research in this area. I’ll reference relevant medical principles in my assessment.”

Language Matters: Phrasing for Medical Opinions

The specific language used in medical opinions can significantly impact how VA evaluates them:

Effective Phrasing	Ineffective Phrasing
“It is at least as likely as not (50% or greater probability) that the veteran’s peripheral neuropathy is caused by his service-connected diabetes mellitus.”	“The veteran’s peripheral neuropathy could be related to his diabetes.”
“The veteran’s service-connected PTSD has permanently aggravated his hypertension beyond its natural progression.”	“The veteran’s PTSD might be contributing to his hypertension.”
“Based on medical literature and my clinical experience, the altered gait from the veteran’s service-connected knee condition has directly contributed to the development of his lumbar degenerative disc disease.”	“There may be a connection between the veteran’s knee problems and his back pain.”
“While the veteran has other risk factors for heart disease, it is my professional opinion that his service-connected diabetes is at least as likely as not the primary contributing factor to his coronary artery disease.”	“The veteran’s heart disease is multifactorial, with diabetes being one of several possible causes.”
“The medical mechanism by which the veteran’s service-connected condition causes his secondary condition is…”	“These conditions are often seen together in patients.”

Encourage your providers to use definitive language that clearly addresses the VA’s standard of proof.

MEDICAL OPINION REGARDING SECONDARY SERVICE CONNECTION

June 15, 2023

RE: John Veteran (VA File #: 123456789)

Provider Information:

Sarah Johnson, M.D.
Board Certified Neurologist
Neurology Associates Medical Group
123 Medical Center Drive
Anytown, USA 12345
Medical License #: MD12345

Qualifications:

I am a board-certified neurologist with 15 years of experience specializing in peripheral nerve disorders. I have been Mr. Veteran’s treating neurologist for the past three years. I have published research on diabetic neuropathy and regularly treat patients with this condition.

Records Reviewed:

• Mr. Veteran’s complete medical records from my practice (2020-2023)
• VA Medical Center records provided by Mr. Veteran (2018-2023)
• EMG/NCS test results dated February 12, 2023
• Laboratory results documenting diabetes control (2018-2023)
• VA Rating Decision dated January 10, 2019, establishing service connection for diabetes mellitus
• Current medical literature regarding diabetic neuropathy

Diagnosis:

Mr. Veteran has been diagnosed with peripheral polyneuropathy affecting both lower extremities. This diagnosis is confirmed by clinical examination findings including decreased sensation to light touch and pinprick in a stocking distribution, absent ankle reflexes bilaterally, and positive Tinel’s sign at both ankles. EMG/NCS testing performed on February 12, 2023, confirms axonal sensorimotor polyneuropathy with predominant sensory involvement, consistent with diabetic neuropathy.

Opinion:

It is my professional medical opinion that it is at least as likely as not (50% or greater probability) that Mr. Veteran’s peripheral polyneuropathy is caused by his service-connected diabetes mellitus type 2. Additionally, even if other factors contributed to the initial development of mild neuropathy, it is at least as likely as not that his diabetes has permanently aggravated his peripheral neuropathy beyond its natural progression.

Rationale:

The medical relationship between diabetes mellitus and peripheral neuropathy is well-established in medical literature. Chronic hyperglycemia leads to metabolic and microvascular changes that damage peripheral nerves through several mechanisms:

1. Increased polyol pathway flux, leading to accumulation of sorbitol and fructose in nerves, causing osmotic stress and decreased nerve myoinositol
2. Formation of advanced glycation end products (AGEs), which damage nerve proteins
3. Oxidative stress from increased free radical production
4. Microvascular insufficiency reducing oxygen supply to nerves
5. Impaired nerve regeneration and axonal transport

In Mr. Veteran’s specific case, several factors support the causal relationship between his diabetes and peripheral neuropathy:

1. Temporal relationship: His neuropathic symptoms began approximately 3 years after his diabetes diagnosis, consistent with the typical progression of diabetic neuropathy
2. Pattern of involvement: The symmetrical, distal, predominantly sensory pattern of his neuropathy is classic for diabetic polyneuropathy
3. Correlation with glycemic control: His records show periods of poor glycemic control (HbA1c >8.5%) preceding worsening of neuropathic symptoms
4. Electrophysiologic findings: His EMG/NCS results show axonal sensorimotor polyneuropathy with predominant sensory involvement, which is the most common pattern in diabetic neuropathy
5. Exclusion of other causes: Evaluation for other common causes of polyneuropathy (including B12 deficiency, thyroid dysfunction, paraproteinemia, and toxic exposures) has been negative

Alternative Causes:

I have considered other potential causes of peripheral neuropathy in Mr. Veteran’s case:

1. Age-related changes: At 62, Mr. Veteran could have some age-related neurological changes, but the severity and pattern of his neuropathy exceed what would be expected from age alone
2. Alcohol use: Mr. Veteran reports moderate alcohol consumption (1-2 drinks weekly), which is well below the threshold typically associated with alcoholic neuropathy
3. Nutritional factors: Laboratory testing shows normal levels of vitamin B12, folate, and other nutritional parameters
4. Prior toxic exposures: While Mr. Veteran reports some chemical exposures during service, the onset of his neuropathy decades later and its clear correlation with his diabetes make diabetes the more likely primary cause

While these factors may contribute to some degree, the preponderance of medical evidence in this case supports diabetes as the primary cause of Mr. Veteran’s peripheral neuropathy. Even if other factors contributed initially, his diabetes has at minimum permanently aggravated his neuropathy beyond its natural progression.

Conclusion:

Based on my examination of Mr. Veteran, review of his medical records, and application of established medical principles, it is my professional opinion that it is at least as likely as not that his peripheral polyneuropathy is caused by his service-connected diabetes mellitus. The pattern, progression, and characteristics of his neuropathy are consistent with diabetic etiology, and other potential causes have been appropriately considered and are less likely to be the primary factors in his condition.

I am available to provide further information or clarification if needed.

Sincerely,

Sarah Johnson, M.D.
Board Certified Neurologist

When to Consider an Independent Medical Examination (IME)

An independent medical examination from a provider who specializes in disability evaluations may be worth the cost in these situations:

• When your treating providers are unwilling to provide opinions
• When your claim involves complex medical relationships
• When you’ve received a negative C&P examination
• When your claim has been denied based on medical evidence
• When you need a comprehensive review of all medical evidence
• When you’re appealing to the Board of Veterans’ Appeals
• When the potential retroactive award would justify the expense

IMEs typically cost $1,000-$3,000 depending on complexity, but can be decisive in difficult cases.

Sample Medical Literature Summary

RE: Medical Literature Supporting Secondary Connection Between PTSD and Hypertension

The following medical literature supports my claim that my service-connected PTSD has caused or aggravated my hypertension:

1. “Posttraumatic Stress Disorder and Incident Cardiovascular Disease: A Systematic Review and Meta-Analysis” (Journal of the American Heart Association, 2019)

Key Findings: This meta-analysis of 4,180,598 participants across multiple studies found that PTSD was associated with a 61% increased risk of developing cardiovascular disease, including hypertension. The authors concluded that “PTSD is independently associated with increased risk of incident cardiovascular diseases.”

Relevance to My Case: Like the subjects in these studies, I developed hypertension after my PTSD diagnosis. My blood pressure readings show a correlation with PTSD symptom severity, with higher readings during periods of increased PTSD symptoms.

2. “Autonomic Nervous System Dysfunction in Psychiatric Disorders and the Impact of Psychotropic Medications” (CNS & Neurological Disorders – Drug Targets, 2017)

Key Findings: This review explains how PTSD causes chronic dysregulation of the autonomic nervous system, leading to persistent elevations in blood pressure through increased sympathetic tone and elevated stress hormones like cortisol and norepinephrine.

Relevance to My Case: My treatment records document autonomic symptoms during PTSD episodes, including increased heart rate, sweating, and elevated blood pressure. My psychiatrist has noted that my hyperarousal symptoms directly impact my cardiovascular function.

3. “VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder” (2017)

Key Findings: This official VA guideline acknowledges that “PTSD is associated with increased risk for hypertension” and recommends monitoring cardiovascular health in PTSD patients.

Relevance to My Case: As a veteran with PTSD receiving care through the VA system, this guideline directly applies to my case and supports the connection between my conditions that my providers have observed.

4. “Sleep Disturbance, Psychiatric Disorders, and Cardiovascular Disease Risk: A Narrative Review” (Nature and Science of Sleep, 2020)

Key Findings: This review explains how sleep disturbances, a core symptom of PTSD, contribute to hypertension through multiple mechanisms including sympathetic activation, inflammation, and endothelial dysfunction.

Relevance to My Case: My VA sleep clinic records document severe insomnia and nightmares related to PTSD, with sleep studies showing elevated nighttime blood pressure. My treatment records show that improvements in sleep correlate with better blood pressure control.

These articles collectively support the medical mechanism by which my service-connected PTSD has caused or permanently aggravated my hypertension, consistent with my provider’s opinion letter and my medical history.

Using Diagnostic Evidence Effectively

To maximize the impact of diagnostic testing in your claim:

1. Highlight key findings in your submissions, don’t expect VA to interpret complex results
2. Connect the dots between test results and the secondary relationship
3. Include provider interpretations that specifically address the connection
4. Document progression through serial testing when possible
5. Compare results to medical literature on expected findings in secondary conditions

Remember that raw test results alone are rarely sufficient—they need interpretation and context to support your claim effectively.