7206§ 3.102§ 3.303§ 3.31038 CFR Part 4, DC 7206 (esophageal stricture criteria; GERD rated here for claims filed on/after 2024-05-19). Isolated hiatal hernia without GERD remains DC 7346.7206§ 3.102§ 3.303§ 3.31038 CFR Part 4, DC 7206 (esophageal stricture criteria; GERD rated here for claims filed on/after 2024-05-19). Isolated hiatal hernia without GERD remains DC 7346.7206§ 3.102§ 3.303§ 3.31038 CFR Part 4, DC 7206 (esophageal stricture criteria; GERD rated here for claims filed on/after 2024-05-19). Isolated hiatal hernia without GERD remains DC 7346.

Nexus letter guide · 7206

Nexus Letter for GERD: What It Must Say

The medical opinion connecting GERD (7206) to your service is the piece of the file a rater weighs most heavily. This is what that letter has to contain — and a complete, real example you can read before writing a word.

Draft yours from your records All nexus letter guides

Sample — Illustrative Specimen

Invented veteran · fictional sample provider · not a signed medical opinion

INDEPENDENT MEDICAL OPINION

Veteran: Samuel Okonkwo (invented veteran — illustrative sample)
Condition at issue: Obstructive Sleep Apnea (ICD-10 G47.33)
Service-connected condition relied upon: Chronic Sinusitis (ICD-10 J32.9)
Basis of claim: Secondary service connection under 38 C.F.R. §§ 3.303, 3.310
Opinion date: August 4, 2026

REASON FOR EVALUATION

This is an independent medical opinion prepared for the purpose of assisting in the determination of eligibility for veterans benefits. Its single question is a medical one: whether Mr. Okonkwo's obstructive sleep apnea is proximately due to, the result of, or aggravated beyond its natural progression by his service-connected chronic sinusitis. It is addressed to the C&P examiner and the VA rating official who will weigh it.

MEDICAL OPINION

It is my opinion that it is at least as likely as not (a 50 percent or greater probability) that Obstructive Sleep Apnea is proximately due to, the result of, or aggravated beyond its natural progression by the veteran's service-connected Chronic sinusitis (38 C.F.R. §§ 3.303, 3.310). In short: but for the veteran's service-connected Chronic sinusitis, Obstructive Sleep Apnea would not have occurred, or would not have progressed to its current severity.

Based on the history and records reviewed and the medical literature governing this condition, I opine that Obstructive Sleep Apnea (ICD-10 G47.33) is proximately due to, the result of, or aggravated by his service-connected Chronic sinusitis (ICD-10 J32.9), under 38 C.F.R. § 3.310. This claim is brought as secondary to Chronic sinusitis, established as service-connected in the veteran's VA claims file; the opinion below rests on that anchor. The mechanism connecting the two conditions — chronic nasal and sinonasal obstruction increasing upper-airway resistance and collapsibility during sleep — is well established in the peer-reviewed literature and applies directly to a claimant, like Mr. Okonkwo, whose sinonasal disease began in service and whose obstructive sleep apnea was later confirmed on polysomnography. My opinion accounts for the recognized non-service risk factors for this condition, none of which displaces the sinonasal pathway as at least an equal and materially contributing cause.

Read all 4,348 words — free

The published example letter — an invented veteran and a fictional sample provider.

Key facts

Rated under: 38 CFR Part 4, DC 7206 (esophageal stricture criteria; GERD rated here for claims filed on/after 2024-05-19). Isolated hiatal hernia without GERD remains DC 7346.
Diagnostic code: 7206
The standard: “At least as likely as not” — 50% or greater
Connection theories: Direct (§ 3.303) or secondary (§ 3.310) · 2 pathways below

The short answer

A GERD nexus letter is a medical opinion that your gastroesophageal reflux disease is "at least as likely as not" caused by your service, or by a condition VA already rates or its treatment, most often anti-inflammatory pain medication for a service-connected injury, PTSD or another mental health condition, or asthma. It needs a documented diagnosis, a timeline showing the reflux followed the cause it names, and a mechanism explained with facts from your records. Know the rating before you file: since the 2024 digestive-system rewrite, VA rates GERD under DC 7206, and every level above 0 percent requires a documented esophageal stricture.

What a nexus letter is

A nexus letter is a written medical opinion from a licensed clinician stating that a veteran’s condition is “at least as likely as not” (a 50 percent or greater probability) connected to their military service — or to a condition already service-connected. It is the bridge between a diagnosis and service connection: the VA has your diagnosis and your service records, and the nexus opinion is what ties them together with medical reasoning a rater can weigh.

The standard · 38 CFR § 3.102

“At least as likely as not”

The opinion does not have to be certain, or even “more likely than not.” A 50 percent or greater probability meets the standard; when the evidence is in approximate balance, the benefit of the doubt goes to the veteran.

What a GERD nexus letter must contain

1
The diagnosis, by name and code
GERD named as a current, documented diagnosis — the condition the VA rates under 38 CFR Part 4, DC 7206 (esophageal stricture criteria; GERD rated here for claims filed on/after 2024-05-19). Isolated hiatal hernia without GERD remains DC 7346. (7206). No diagnosis, no service connection: the opinion has to be about a condition that exists in your records.
2
The theory of connection
Direct service connection under 38 C.F.R. § 3.303 (the condition began in or was caused by service), or secondary service connection under § 3.310 (a service-connected condition caused or aggravated it). For GERD, the secondary path is common — see the mechanisms below — and the letter must name which theory it is using.
3
The magic words, used correctly
The opinion must be stated to the VA's own standard: "at least as likely as not (a 50 percent or greater probability)." Weaker hedges like "possibly" or "may be related" fail; the standard is a specific legal threshold, and letters that don't invoke it get discounted.
4
A rationale, not a conclusion
The most common fatal flaw is the conclusory letter — an opinion with no reasoning. A rater is instructed to weigh the rationale: what in the records supports the connection, what the medical literature says about the mechanism, and why known alternative causes don't displace it. For GERD specifically: EGD/barium-swallow/CT documenting an esophageal STRICTURE (not reflux esophagitis alone) + dilatation history; every compensable level — even 10% — requires a documented stricture history, so without one the schedular level is 0% and extraschedular (§3.321(b)(1)) is the realistic path above it. (GERD = DC 7206 since 2024-05-19; hiatal hernia is DC 7346, which is rated as esophageal stricture under DC 7203 — the same stricture table.).
5
A licensed clinician's signature and credentials
The letter is medical evidence only when a licensed clinician — opining within their specialty — reviews it, exercises independent judgment, and signs it with their credentials. VA Claim Commander drafts the letter from your records and your story; your clinician signs it. An unsigned draft is a draft.

What a rater looks for in a GERD nexus letter

A documented diagnosis
GERD diagnosed by a provider, ideally with an upper endoscopy (EGD) or other study in the record. "Heartburn" in a problem list, or an over-the-counter antacid, gives the rater little to connect.
The right condition named
Reflux, gastritis, and ulcers are different diagnoses. Anti-inflammatory pain relievers are better known for causing gastritis and ulcers than reflux, so if your endoscopy shows gastritis or an ulcer, that may be the more accurate claim, and the letter should say what the study actually found.
A timeline that fits the theory
When you started the medication or when the service-connected condition began, and when reflux symptoms and treatment started. Reflux that began years before the cause the letter names points toward aggravation, not causation.
The mechanism, specific to you
For medication: which drug, the dose and how long, prescribed for which service-connected condition. For PTSD: how stress, sleep disruption, and psychiatric medications affect acid and the lower esophageal sphincter, tied to your chart. For asthma: how coughing, pressure changes, and some asthma medications promote reflux.
The other causes, addressed
Weight, smoking, alcohol, diet, a hiatal hernia, and age. A letter that names the ones in your file and explains why the service-connected cause still contributes is much harder to set aside.

Direct service connection for GERD

Most GERD claims are secondary, but a direct claim under 38 C.F.R. § 3.303 works when the reflux began in service. What a nexus letter can build on:

Sick-call visits in service
Heartburn, reflux, or chest burning noted in your service treatment records, or antacids and acid reducers prescribed while you were in.
Continuous treatment since
An acid reducer started in service or soon after, and refilled since, shows the condition did not start fresh after discharge.

Example gerd nexus letter wording

The opinion section of a GERD nexus letter on a medication theory, for an invented veteran. A real letter is written by the clinician about your records, and the facts in it have to be yours.

Sample — Illustrative Specimen

Invented veteran · not a real medical opinion · do not copy as your own

Opinion: It is my medical opinion that the veteran's gastroesophageal reflux disease is at least as likely as not (a 50 percent or greater probability) caused by the anti-inflammatory medication prescribed for his service-connected lumbar spine condition. In the alternative, it is at least as likely as not that this medication has aggravated his reflux beyond its natural progression.

Records reviewed: VA treatment records 2012 to 2026, including the pharmacy history; the esophagogastroduodenoscopy of April 2024 showing erosive esophagitis; and the rating decision service-connecting the lumbar spine.

History: The veteran was prescribed naproxen daily for back pain from 2013. Reflux symptoms were first recorded in 2015 and omeprazole was started that year. He reports no reflux before starting the medication, and none is recorded in earlier notes.

Rationale: Nonsteroidal anti-inflammatory drugs reduce the protective prostaglandins that defend the lining of the esophagus and stomach, and they are a recognized contributor to erosive esophagitis. The sequence here, daily use for a service-connected condition followed within two years by documented reflux and later endoscopic esophagitis, supports that link. I considered weight, smoking, and alcohol: he has never smoked, drinks rarely, and his weight has been stable. No hiatal hernia was seen on endoscopy.

Filing GERD as a secondary condition

Under 38 C.F.R. § 3.310, if a service-connected condition caused or aggravated GERD, it is service-connected too. The nexus letter’s job becomes explaining the medical mechanism. The pathways veterans most commonly file:

PTSD / Mental HealthGERD

GERD secondary to PTSD / Mental Health

PTSD-related stress hormones slow gastric emptying and increase gastric acid production, directly causing or worsening acid reflux.

What proves it: GI records documenting GERD; gastroenterologist or primary care statement noting the established link between chronic psychological stress and GERD.

Full guide: GERD secondary to PTSD / Mental Health

AsthmaGERD

GERD secondary to Asthma

Asthma increases intrathoracic pressure changes that promote gastric acid reflux, and bronchodilator medications relax the lower esophageal sphincter, worsening GERD.

What proves it: GI records documenting GERD; pulmonologist or gastroenterologist nexus linking asthma physiology and medication effects to acid reflux development.

Full guide: GERD secondary to Asthma

Conditions often claimed secondary to GERD

Once GERD is service-connected, conditions it causes or makes worse can be claimed under 38 C.F.R. § 3.310. Each one needs its own nexus opinion explaining that link.

Why nexus letters fail

Conclusory: an opinion with no rationale. The rater is told to weigh reasoning, and a bare “it’s related” weighs nothing.
Wrong standard: “may be related” or “possibly caused by” instead of “at least as likely as not.”
Ignores the other causes: a strong letter names the recognized non-service risk factors and explains why they don’t displace the service connection.
Outside the specialty: a clinician opining far from their field gets less weight than one whose practice covers the condition.
Unsigned: a draft nobody signed is not medical evidence — it is homework.

Who can write a GERD nexus letter

Any licensed clinician qualified to give a medical opinion on GERD: a physician, or another licensed clinician opining within their field. VA's test is whether the person is qualified by education, training, or experience (38 C.F.R. § 3.159(a)(1)). It does not have to be a VA doctor. Your own treating provider, who already knows your history, is often the strongest choice.

VA Claim Commander drafts the letter from your records and your own words, so your clinician starts from a complete draft; they review it, change what they disagree with, and sign only if it is their opinion.

If your own doctor won't write one, a licensed clinician through Commander Health can review your records and, only if the evidence supports it, write and sign a nexus letter for GERD. It is a flat $500 that includes the records review, separate from any VA Claim Commander plan, and the clinician can decline if your records don't support an opinion.

Ask your own doctor: draft the request Commander Health nexus letter

Common questions

Do I need a nexus letter for a GERD VA claim?

If service connection isn't already established for GERD, a medical nexus opinion is usually the piece a rater weighs most heavily. It connects the diagnosis (7206) to your service — or to an already service-connected condition — using the "at least as likely as not" standard. Presumptive claims are the main exception.

What must a nexus letter for GERD say?

Four things: the current diagnosis by name and diagnostic code; the connection theory (direct under 38 C.F.R. § 3.303, or secondary under § 3.310); the opinion stated to the "at least as likely as not (50 percent or greater probability)" standard; and a medical rationale grounded in your records and the medical literature — not a bare conclusion. It must be signed by a licensed clinician.

Who has to sign a nexus letter?

A licensed medical professional — a physician, or another clinician opining within their specialty (38 C.F.R. § 3.159(a)(1) asks for someone qualified by education, training, or experience). VA Claim Commander drafts the letter from your own records and story; a licensed clinician reviews, exercises independent judgment, and signs. An unsigned draft is not medical evidence. If your own doctor won't write one, a licensed clinician through Commander Health can review your records and, only if the evidence supports it, write and sign a nexus letter for GERD. It is a flat $500 that includes the records review, separate from any VA Claim Commander plan, and the clinician can decline if your records don't support an opinion.

Can GERD be claimed secondary to another condition?

Yes — veterans commonly file GERD secondary to PTSD / Mental Health, Asthma under 38 C.F.R. § 3.310. In a secondary claim, the nexus letter's job changes: instead of connecting GERD to service directly, it explains the medical mechanism by which the service-connected condition caused or aggravated it.

How does VA rate GERD now?

Since the 2024 rewrite of the digestive-system rules, GERD is rated under DC 7206 in 38 C.F.R. § 4.114, at 10, 30, 50, or 80 percent, and every one of those levels requires a documented esophageal stricture. The findings have to be documented by barium swallow, CT, or endoscopy. Reflux controlled with daily medication and no stricture generally rates 0 percent.

Is it worth service-connecting GERD at 0 percent?

It can be. A service-connected condition at 0 percent can be increased later if it gets worse, and conditions caused by it, such as dental erosion or a stricture, can be claimed secondary to it. Whether that is worth the effort is your call, but it helps to know the likely number before you pay for an opinion.

Can GERD be secondary to PTSD?

It can be claimed that way under 38 C.F.R. § 3.310. The opinion needs to explain how PTSD or the medications used to treat it caused or worsened the reflux, with the timeline from your records. VA decides whether the evidence is enough.

Can GERD be secondary to pain medication?

Yes, when the medication was prescribed for a service-connected condition. The letter should name the drug, the dose, and how long you took it, and show the reflux followed. Because these drugs are better known for causing gastritis and ulcers, the letter should also say clearly what your diagnosis is.

How the VA rates GERD →GERD secondary to PTSD: building the connection →GERD secondary to asthma →VA disability calculator →

Read a complete nexus letter — free, no account

4,348 words, 11 verified studies, the § 3.310 secondary framework — published in full so you can see the standard before you write a word.

Read the example letter Draft yours from your own records

Drafts are prepared for review and signature by a licensed clinician. Documentation quality is the promise — never a claim outcome.

Nexus Letter for GERD: What It Must Say

The short answer

What a nexus letter is

What a GERD nexus letter must contain

The diagnosis, by name and code

The theory of connection

The magic words, used correctly

A rationale, not a conclusion

A licensed clinician's signature and credentials