Introduction to the Appeals Process

Receiving a denial on your secondary service connection claim can be disheartening, but it’s important to understand that this is often just the beginning of the process. The VA appeals system provides multiple opportunities to present additional evidence, correct misunderstandings, and ultimately secure the benefits you deserve. This chapter provides a comprehensive guide to understanding why secondary claims are denied and how to effectively navigate the appeals process.

This chapter will guide you through each step of challenging a denial, from understanding the decision letter to selecting the most appropriate appeal option and developing the evidence needed to overturn the denial. With the right approach, many initially denied claims can ultimately be approved through the appeals process.

Understanding Why Secondary Claims Are Denied

Before developing an effective appeal strategy, it’s essential to understand exactly why your claim was denied. Secondary service connection claims are typically denied for specific reasons that can be addressed with targeted evidence and arguments.

Common Denial Reasons for Secondary Claims

Secondary service connection claims are most frequently denied for the following reasons:

Analyzing Your Decision Letter

The decision letter (also called a Rating Decision) contains critical information that will guide your appeal strategy:

• Evidence section: Lists what evidence VA considered
• Decision section: States what was decided for each claimed condition
• Reasons and Bases section: Explains why each decision was made
• Laws and Regulations section: Cites legal standards applied to your claim

Strategy: Carefully review the “Reasons and Bases” section to identify the specific reason(s) for denial. This section will tell you exactly what evidence was found lacking or what issues need to be addressed in your appeal.

Obtaining Your Claims File (C-File)

Before developing your appeal strategy, it’s essential to obtain and review your complete claims file (C-file):

• What’s in your C-file:
  • All previous claims and decisions
  • Service treatment records
  • VA medical records
  • Private medical records submitted to VA
  • C&P examination reports
  • VA internal notes and opinions
  • Correspondence between you and VA
• How to request your C-file:
  • Submit VA Form 20-10206 (Request for and Authorization to Release Records)
  • Request through VA.gov
  • Ask your VSO or representative to access it
  • File a Freedom of Information Act (FOIA) request
• What to look for:
  • C&P examiner’s complete rationale (often more detailed than what appears in decision letter)
  • Evidence that was submitted but not mentioned in the decision
  • Internal VA medical opinions
  • Notes about what evidence would be sufficient to grant the claim
  • Potential duty to assist violations

Strategy: Pay particular attention to the C&P examination report, which often contains more detailed reasoning than what appears in the decision letter. Understanding the examiner’s complete rationale can help you directly address their specific concerns in your appeal.

Understanding the Appeals Modernization Act (AMA) System

Since February 2019, all VA appeals are processed under the Appeals Modernization Act (AMA) system, which provides multiple options for challenging a denial. Understanding these options is essential for developing an effective appeal strategy.

The Three Appeal Lanes

Under the AMA, veterans have three main options (or “lanes”) for appealing a decision:

Strategic Selection of Appeal Options

Choosing the right appeal option depends on your specific situation:

• Supplemental Claim is generally best when:
  • You have new medical opinions addressing the nexus requirement
  • You’ve obtained additional medical records supporting your claim
  • You have new lay evidence documenting symptoms or progression
  • You’ve found medical literature supporting the connection
  • You need to submit evidence addressing alternative causes
• Higher-Level Review is generally best when:
  • VA overlooked or misinterpreted evidence already in your file
  • VA misapplied a law or regulation
  • VA made a clear procedural error
  • The C&P examination was inadequate but you don’t have new evidence
  • VA failed to consider favorable evidence already submitted
• Board Appeal is generally best when:
  • Lower-level appeals have been unsuccessful
  • Your case involves complex legal or medical issues
  • You want to establish a legal precedent
  • You need to present testimony directly to a Veterans Law Judge
  • You have representation experienced with Board appeals

Strategy: For most secondary service connection denials, starting with a Supplemental Claim is often the most effective approach, as it allows you to directly address the evidence gaps identified in the denial while maintaining a relatively quick processing time.

Effective Dates and Continuous Pursuit

Understanding how effective dates work under the AMA is important for preserving your potential back pay:

• Continuous pursuit: As long as you file your appeal within one year of each decision, you maintain your original effective date
• Supplemental Claims: If filed within one year of a decision, preserves the effective date of the original claim
• Higher-Level Review: If filed within one year of a decision, preserves the effective date of the original claim
• Board Appeal: If filed within one year of a decision, preserves the effective date of the original claim
• After one year: If you wait more than one year after a decision to file an appeal, your effective date will generally be the date of the new appeal

Strategy: Always file your next appeal within one year of each decision to preserve your original effective date. If you’re approaching the one-year mark and aren’t ready with all your evidence, file the appeal form anyway and note that additional evidence will be submitted later.

Developing Evidence for Appeals

The success of your appeal often depends on the quality and relevance of the evidence you develop. This section explores strategies for obtaining and presenting compelling evidence that addresses the specific reasons for your denial.

Medical Opinion Strategies

Medical opinions are often the most critical evidence for secondary service connection appeals:

• Elements of an effective medical opinion:
  • Clear statement using “at least as likely as not” language
  • Specific identification of both conditions
  • Explanation of the biological mechanism of connection
  • Discussion of relevant medical literature
  • Consideration and rebuttal of alternative causes
  • Explanation of why the opinion differs from VA examiners (if applicable)
  • Reference to specific findings in your medical history
• Sources for medical opinions:
  • Treating physicians who know your medical history
  • Specialists in the relevant field
  • Independent medical examiners
  • Medical consultants who specialize in VA claims
  • University medical centers with research expertise
• Provider qualifications:
  • Opinions from specialists in the relevant field carry more weight
  • Include the provider’s CV or statement of qualifications
  • Note any special expertise in veterans’ health issues
  • Highlight if the provider has treated you long-term

Strategy: Provide your medical provider with a “medical opinion checklist” outlining exactly what needs to be addressed, including the specific language from your denial, the correct legal standard, and the key elements that should be covered in their opinion.

Medical Literature Strategies

Medical literature can significantly strengthen your appeal, especially when properly presented:

• Finding relevant research:
  • PubMed (pubmed.ncbi.nlm.nih.gov)
  • Google Scholar (scholar.google.com)
  • VA/DoD Clinical Practice Guidelines
  • Medical association position papers
  • Textbooks on the relevant conditions
• Effective presentation:
  • Don’t just submit articles; explain their relevance
  • Highlight specific passages supporting your claim
  • Create a summary of key findings from multiple sources
  • Have a medical professional interpret the literature in context of your case
  • Address any contradictory literature cited by VA
• Types of literature to prioritize:
  • Meta-analyses and systematic reviews
  • Large-scale epidemiological studies
  • VA or military population studies
  • Recent research reflecting current medical understanding
  • Studies specifically addressing secondary relationships

Lay Evidence Strategies

Personal statements and statements from witnesses can provide crucial context for medical evidence:

• Personal statements:
  • Describe the timeline of symptom development
  • Explain observed relationships between conditions
  • Document functional limitations and quality of life impacts
  • Address specific points raised in the denial
  • Describe treatment history and responses
• Witness statements:
  • Statements from family members who observe daily symptoms
  • Coworker observations about workplace limitations
  • Statements from friends who have witnessed condition progression
  • Former military colleagues who can verify condition onset
  • Caregivers who assist with managing conditions
• Effective presentation:
  • Use VA Form 21-4138 (Statement in Support of Claim) or personal letterhead
  • Organize chronologically or by topic
  • Be specific about dates, symptoms, and observations
  • Explain the relationship between observations and medical findings
  • Focus on facts rather than medical conclusions

Strategy: Create a symptom journal documenting the relationship between your service-connected condition and secondary condition over time. This contemporaneous documentation can be powerful evidence of the connection between conditions.

Addressing Alternative Causes

Many secondary claims are denied because VA attributes the condition to other causes. Effective appeals directly address these alternative explanations:

• Common alternative causes cited by VA:
  • Age-related changes
  • Genetic predisposition
  • Weight or lifestyle factors
  • Pre-existing conditions
  • Post-service injuries or exposures
  • Common comorbidities unrelated to service
• Effective response strategies:
  • Acknowledge other factors but explain why service-connected condition is at least contributory
  • Provide medical opinions addressing relative contribution of different factors
  • Document timeline inconsistent with alternative causes
  • Highlight atypical presentation or progression not explained by alternative causes
  • Provide medical literature on multifactorial causation
  • Emphasize that service connection requires only that the condition is “at least as likely as not” related, not that it is the sole cause

Strategy: Remember that VA’s standard is “at least as likely as not” (50% or greater probability). You don’t need to prove your service-connected condition is the only cause, just that it is at least as likely as not a contributing factor.

Preparing Effective Appeal Submissions

How you organize and present your appeal can significantly impact its success. This section provides strategies for preparing clear, compelling appeal submissions.

Supplemental Claim Strategies

When filing a Supplemental Claim (VA Form 20-0995), consider these strategies:

• Clearly identify new and relevant evidence:
  • List each piece of new evidence in Section IX of the form
  • Explain why each item is both new (not previously considered) and relevant (relates to the reason for denial)
  • If evidence is not yet available, note what is being obtained and approximate timeframe
• Submit a cover letter:
  • Summarize the history of the claim
  • Identify the specific denial being appealed
  • Explain how the new evidence addresses the reason for denial
  • Reference relevant regulations and case law
  • Provide a clear roadmap of the evidence being submitted
• Organize evidence effectively:
  • Create a table of contents for multiple documents
  • Use tabs or clear labeling for different evidence types
  • Highlight key passages in lengthy documents
  • Include an evidence summary explaining the relevance of each item
  • Present evidence in logical order (chronological or by importance)

Strategy: Create an “Evidence Map” that explicitly connects each piece of new evidence to the specific reason for denial. This makes it easy for the VA adjudicator to see how you’ve addressed the deficiencies in your original claim.

Higher-Level Review Strategies

When requesting a Higher-Level Review (VA Form 20-0996), consider these strategies:

• Request an informal conference:
  • Check the box for an informal conference in Section III
  • Prepare talking points focusing on specific errors
  • Be concise and focused during the conference (typically 15-30 minutes)
  • Have all relevant file numbers and dates available
  • Take notes on what the reviewer says for future reference
• Clearly identify errors:
  • In Section V, specifically identify each error you believe occurred
  • Reference specific evidence that was misinterpreted or overlooked
  • Cite relevant laws, regulations, or procedures that were misapplied
  • Identify any duty to assist violations
  • Be specific about how the error affected the outcome
• Submit a written argument:
  • Though not required, a written argument can help the reviewer understand your position
  • Focus on facts already in the record, not new evidence
  • Cite specific page numbers from your claims file when possible
  • Reference relevant case law or VA procedures
  • Clearly explain why the evidence of record supports your claim

Strategy: Remember that Higher-Level Review does not allow submission of new evidence. Focus entirely on explaining why the evidence already in your file should have led to a different decision.

Board Appeal Strategies

When filing a Board Appeal (VA Form 10182), consider these strategies:

• Selecting the right docket:
  • Direct Review: Choose when you believe the evidence already in your file supports your claim and you want the fastest decision
  • Evidence Submission: Choose when you have new evidence but don’t need a hearing (submit evidence within 90 days of filing)
  • Hearing: Choose when you want to testify before a Veterans Law Judge and submit new evidence (longest wait time)
• Preparing a written brief:
  • Consider having a representative help prepare a formal legal brief
  • Clearly identify each error in the prior decision
  • Cite relevant statutes, regulations, and case law
  • Reference specific evidence by exhibit number or page in claims file
  • Present logical arguments explaining why the evidence supports your claim
  • Address any negative evidence and explain why it should be given less weight
• Preparing for a hearing (if selected):
  • Prepare a written outline of key points to cover
  • Practice answering likely questions
  • Review your entire claims file before the hearing
  • Be prepared to explain the medical connection in layman’s terms
  • Consider having witnesses who can provide relevant testimony
  • Dress professionally and be respectful but confident

Strategy: Board appeals benefit significantly from professional representation. Consider obtaining assistance from a veterans service organization (VSO), accredited claims agent, or attorney experienced in VA appeals.

Working with Representatives

While you can handle appeals on your own, working with a qualified representative often significantly improves your chances of success, especially for complex secondary service connection claims.

Types of Representatives

Several types of representatives can assist with VA appeals:

• Veterans Service Organizations (VSOs):
  • Organizations like DAV, VFW, American Legion, etc.
  • Services are free
  • Varying levels of expertise and resources
  • May handle many cases simultaneously
  • Good option for straightforward appeals
• Accredited Claims Agents:
  • Non-attorneys accredited by VA to represent veterans
  • May charge fees for work on appeals (not initial claims)
  • Often specialize in VA claims
  • Typically handle fewer cases than VSOs
  • Good middle option between VSOs and attorneys
• Attorneys:
  • Must be accredited by VA to represent veterans
  • May charge fees for work on appeals (not initial claims)
  • Often have specialized knowledge and resources
  • Particularly valuable for complex cases or Board appeals
  • Can provide representation in court if needed

Strategy: Consider the complexity of your case when selecting representation. For straightforward secondary connections with clear medical evidence, a VSO may be sufficient. For complex cases involving multiple conditions, conflicting medical opinions, or legal issues, an attorney may be worth the investment.

When to Consider Professional Representation

Professional representation is particularly valuable in certain situations:

• Complex medical relationships that are difficult to explain
• Multiple denials despite submitting additional evidence
• Legal issues involving interpretation of regulations or case law
• Board appeals, which benefit from formal legal arguments
• Cases involving multiple conditions with interrelated effects
• Situations where VA has made procedural errors that need to be addressed
• When you’re approaching appeal deadlines and need immediate assistance

Strategy: If you’ve received multiple denials despite submitting what you believe is strong evidence, it may be time to seek professional representation. A fresh perspective from someone experienced with VA claims can often identify issues or opportunities you might have missed.

Working Effectively with Representatives

To get the most from your representative relationship:

• Be organized:
  • Provide a complete chronological summary of your claim
  • Organize all relevant documents before your first meeting
  • Create a timeline of your medical conditions and treatments
  • Prepare a list of all healthcare providers who have treated you
  • Have copies of all previous VA decisions and submissions
• Be responsive:
  • Promptly provide any information or documents requested
  • Attend all scheduled appointments or examinations
  • Return calls or emails in a timely manner
  • Follow through on any tasks assigned to you
  • Keep your contact information updated
• Be honest:
  • Disclose all relevant medical history, even if potentially unfavorable
  • Don’t exaggerate symptoms or relationships between conditions
  • Acknowledge other potential causes or contributing factors
  • Share any concerns or questions about the process
  • Provide complete information about prior claims and appeals

Strategy: Prepare a one-page “case summary” for your representative that includes your name, claim number, service dates, service-connected conditions with ratings, the condition(s) you’re seeking secondary service connection for, key medical evidence, and a brief timeline of your claim history. This helps your representative quickly understand your situation.

Conclusion

Successfully challenging a denial of secondary service connection requires understanding why your claim was denied, selecting the appropriate appeal option, developing targeted evidence, and presenting your case effectively. While the appeals process can be lengthy and sometimes frustrating, many initially denied claims are ultimately approved when veterans persist with well-supported appeals.

Remember these key principles when appealing a denied secondary service connection claim:

• Understand the specific reason for your denial before developing your appeal strategy
• Select the appeal option that best fits your situation and the evidence you have available
• Develop targeted evidence that directly addresses the reason for denial
• Present your evidence clearly with explanations of how it supports your claim
• Consider professional representation for complex cases or after multiple denials
• Maintain continuous pursuit to preserve your effective date
• Be persistent but strategic in your approach to appeals

With the right approach and evidence, you can navigate the appeals process successfully and obtain the benefits you deserve for conditions that are secondary to your service-connected disabilities.