Learn more about our Level 0 Reviews
You may already believe strongly that your medical condition is related to your military service. You may have researched the medical literature, identified relevant exposures, or even found studies discussing an association between your condition and your service history.
But a nexus letter requires something different.
The physician signing the opinion must independently determine whether your individual medical history, service or exposure evidence, relevant scientific literature, and other potential risk factors support the requested medical conclusion.
Our Level 0 Medical Nexus Feasibility Review is designed to answer that question before you invest in a full nexus opinion.
If the physician determines that a nexus opinion is medically supportable and you proceed to a Level 2 or higher nexus service for the same condition, the Level 0 fee is credited toward that service in accordance with our current fee policy.
We hear this question often.
Level 0 is not a research service for Veterans who have not done their homework. Furthermore, recommending a Level 0 does not mean that we doubt your diagnosis, your military service, or your account of what happened.
It means the medical relationship itself requires physician analysis before we can responsibly agree to provide a favorable nexus opinion.
Research showing that an exposure can be associated with a disease is only one part of a nexus analysis. Before signing a medical opinion, the physician may also need to determine:
The purpose of Level 0 is to make that assessment before proceeding with a more extensive nexus report.
Not every claim needs a Level 0 review. Some cases have a relatively straightforward medical theory and sufficient documentation to proceed directly to a nexus opinion.
We are more likely to recommend a Level 0 review when a claim involves:
Claims involving burn pits, PFAS/AFFF, solvents, fuels, benzene, TCE, industrial chemicals, contaminated water, occupational exposures, or other toxic exposure risk activities may require careful evaluation of both the exposure evidence and the scientific literature.
Many diseases have multiple recognized risk factors. A medical nexus analysis may require consideration of age, smoking history, occupational history, family history, post-service exposures, and other potential contributors.
A proposed relationship may be medically plausible but not sufficiently established to justify a favorable nexus opinion without additional analysis.
If the VA has already obtained an unfavorable medical opinion, we may need to determine whether there is a medically defensible basis to disagree with it before preparing another opinion.
Finding a published study does not necessarily establish causation. The physician must evaluate the quality, relevance, and applicability of the available evidence to the individual Veteran.
Suppose a Veteran develops bladder cancer after military service and believes that exposure to fuels, solvents, burn pits, or combustion products caused the disease. The Veteran may find scientific studies discussing bladder cancer and occupational chemical exposures. That research can be helpful, but it does not automatically establish an individual nexus.
The physician would still need to evaluate:
Exposure: What substances was the Veteran actually exposed to? How frequently and for how long? Is the exposure documented or conceded by VA?
Disease: What type of bladder cancer was diagnosed, and when?
Scientific evidence: Does the medical literature support the specific exposure-disease relationship being claimed?
Individual risk factors: Does the Veteran have a history of smoking, relevant civilian occupational exposures, or other established risk factors?
Prior VA findings: Has VA conceded a Toxic Exposure Risk Activity (TERA)? What did the prior C&P examiner conclude, and why?
Level 0 allows the physician to evaluate these issues in order to determine whether a favorable nexus opinion can be medically supported.
Level 0 is a physician medical review — it is not simply an administrative screening.
The physician reviews the relevant records and evaluates the proposed nexus,
based on the available medical and scientific evidence.
You receive a written assessment explaining:
The Level 0 review concludes with one of two outcomes:
A Level 0 review is complete when the written assessment is issued and is not held open while additional records are obtained. If you later obtain new evidence relevant to issues identified in the original assessment, that evidence may be submitted through a separate Supplemental Records Review for an additional fee.
You may choose to proceed to the appropriate full nexus letter service.
When the Level 0 review and subsequent nexus service are for the same medical condition, your Level 0 fee is credited toward the eligible Level 2 or higher service, in accordance with our current fee policy.
When the Level 0 assessment supports proceeding, it can serve as the first stage of the nexus evaluation rather than an entirely separate expense.
A favorable opinion is never guaranteed.
Sometimes the evidence currently available does not provide a sufficient medical basis to support the requested relationship or an “at least as likely as not” nexus opinion. In that situation, your Level 0 report will explain the principal reasons the claim is not medically supportable at this time.
When appropriate, the report may also include a section titled Evidence That Could Help Support Your Claim. This section identifies specific evidence that could address important deficiencies identified during the physician's review.
For example, the physician may identify the need for more specific documentation of an occupational or toxic exposure, medical records establishing onset or continuity of symptoms, relevant diagnostic testing, specialist records, or other evidence directly related to the medical nexus question.
Identifying such evidence does not guarantee that a favorable nexus opinion will ultimately be medically supportable. Rather, it provides a roadmap regarding the specific evidentiary issue preventing the physician from proceeding based on the current record.
The Level 0 review is complete when the written assessment is issued. Additional records submitted afterward are not reviewed as part of the completed Level 0 service.
If you later obtain evidence that substantially addresses the specific deficiency identified in your Level 0 report, you may submit that evidence when requesting a Level 2 or Level 3 nexus opinion. The physician will evaluate the new evidence as part of that service to determine whether a formal nexus opinion can then be medically supported.
It is because an independent medical opinion must actually be independent.
Our physicians do not begin with a predetermined conclusion and then search for evidence to support it. Payment is for the physician's professional review, analysis, and
medical judgment — not for a guaranteed favorable opinion.
This protects the integrity of the medical opinion and, ultimately,
the Veteran who intends to submit it as evidence.
We do not require every Veteran to complete Level 0 before obtaining a nexus letter.
If the proposed relationship is sufficiently established and the records are appropriate for the requested service, we may recommend proceeding directly to a full medical opinion.
Level 0 is primarily intended for cases where medical feasibility itself requires meaningful analysis before the physician can responsibly commit to a nexus opinion.
You don't need to determine this by yourself. Let us help.
Submit your intake information and tell us about your diagnosis, military service, proposed nexus, prior VA decisions, and relevant exposures. We can determine which service level appears most appropriate based on the information provided.
Read more about our Nexus Letter Services.
View our Nexus Letter Fees.
All medical opinions are independent and evidence-based. Acceptance of a case or payment for a review does not guarantee a favorable medical opinion or VA benefits determination.