6260§ 3.102§ 3.303§ 3.31038 CFR Part 4, DC 62606260§ 3.102§ 3.303§ 3.31038 CFR Part 4, DC 62606260§ 3.102§ 3.303§ 3.31038 CFR Part 4, DC 6260
Nexus letter guide · 6260
Nexus Letter for Tinnitus: What It Must Say
The medical opinion connecting Tinnitus (6260) 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.
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.
The published example letter — an invented veteran and a fictional sample provider.
Key facts
Rated under
38 CFR Part 4, DC 6260
Diagnostic code
6260
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 tinnitus nexus letter is a medical opinion saying your recurrent tinnitus is "at least as likely as not" (a 50 percent or greater chance) caused by noise you were exposed to in service, or by a service-connected condition such as hearing loss or a head injury. The strongest ones name the specific noise (your job, weapons, aircraft, engines), rely on your own account of when the ringing started, and explain why a normal hearing test at separation does not rule tinnitus out. Tinnitus is rated at a single 10 percent under 38 C.F.R. § 4.87, DC 6260, so the letter's job is service connection, and once tinnitus is service-connected it can anchor secondary claims such as insomnia.
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”
“possibly” · “may be related”Meets the standard
0%50%100%
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 Tinnitus nexus letter must contain
1
The diagnosis, by name and code
Tinnitus named as a current, documented diagnosis — the condition the VA rates under 38 CFR Part 4, DC 6260 (6260). 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 Tinnitus, 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 Tinnitus specifically: Audiologist diagnosis + documented in-service noise exposure.
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 Tinnitus nexus letter
Recurrent tinnitus, documented
Tinnitus is something only you can hear, so the diagnosis rests on what you report. The letter should state that you have recurrent tinnitus, in one or both ears, and how often it is present.
The noise, named specifically
Your duties and what you were around: artillery, small arms ranges, flight lines, engine rooms, generators, blasts. "Military noise" in general gives the rater less to weigh than the job and the equipment.
When it started, in your words
Ringing is something a veteran is competent to describe (38 C.F.R. § 3.159(a)(2)). The letter should record when you first noticed it and that it has continued, and the clinician can rely on that account when it fits the rest of the record.
A reason beyond the separation hearing test
The most common negative opinion says hearing was normal at separation, so the tinnitus is not related. A strong letter explains why tinnitus from noise injury can occur without measurable hearing loss, rather than resting on the audiogram alone.
The other causes, addressed
Noise after service at work or from hobbies, age, medications, and other ear conditions. A letter that names these and explains why service noise is still the likely cause is harder to set aside.
Direct service connection for Tinnitus
Most tinnitus claims are direct, under 38 C.F.R. § 3.303: the ringing began with noise or an injury in service. What a nexus letter usually builds on:
Noise from your duties
Your personnel records show what you did. Jobs around weapons, aircraft, vehicles, and machinery are the most common basis.
A blast or a single loud event
An explosion, a weapon fired close by, or another acoustic trauma, especially if it is noted in service records or described by people who were there.
A head injury
Tinnitus can follow a traumatic brain injury. If the TBI is service-connected, tinnitus can be claimed as secondary to it instead.
Example tinnitus nexus letter wording
The opinion section of a tinnitus nexus letter, 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 recurrent bilateral tinnitus is at least as likely as not (a 50 percent or greater probability) caused by his exposure to hazardous noise during active service.
Records reviewed: service treatment records; the DD-214 showing service as a field artillery crewmember from 2004 to 2010; VA treatment records; and the audiology evaluation of March 2026, which documents recurrent tinnitus in both ears.
History: The veteran reports ringing in both ears that began during live-fire training in 2006 and has been present since, worst at night in a quiet room. This account is consistent with his documented duties.
Rationale: Repeated exposure to impulse noise from artillery fire is a well-recognized cause of tinnitus. Noise can injure the inner ear and produce tinnitus even when a standard hearing test stays within normal limits, so the normal separation audiogram does not rule out a noise-related cause. I considered noise after service: the veteran has worked in an office since 2011 and reports no recreational shooting. I considered age and medications: neither accounts for tinnitus that began at age 24 during artillery training.
Filing Tinnitus as a secondary condition
Under 38 C.F.R. § 3.310, if a service-connected condition caused or aggravated Tinnitus, it is service-connected too. The nexus letter’s job becomes explaining the medical mechanism. The pathways veterans most commonly file:
TBI / Traumatic Brain InjuryTinnitus
Tinnitus secondary to TBI / Traumatic Brain Injury
Blast-wave TBI and direct head trauma frequently damage the auditory cortex and cochlear hair cells simultaneously, causing persistent tinnitus.
What proves it: Audiology evaluation; ENT or audiologist nexus letter linking tinnitus onset to the TBI event, especially blast-related injuries.
Cochlear hair cell damage from noise trauma that causes hearing loss simultaneously produces the phantom ringing or buzzing of tinnitus through the same mechanism.
What proves it: Audiology evaluation confirming tinnitus; audiologist or ENT nexus letter noting that noise-induced cochlear damage is the common cause of both conditions.
Tinnitus is capped at 10 percent, but the conditions it leads to are not. Veterans file insomnia, headaches, depression, and anxiety secondary to service-connected tinnitus. Sleep apnea is a different matter: tinnitus does not block the airway, and that theory is hard to support.
Once Tinnitus 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.
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 Tinnitus nexus letter
Any licensed clinician qualified to give a medical opinion on Tinnitus: 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 Tinnitus. 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.
If service connection isn't already established for Tinnitus, a medical nexus opinion is usually the piece a rater weighs most heavily. It connects the diagnosis (6260) 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 Tinnitus 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 Tinnitus. 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 Tinnitus be claimed secondary to another condition?
Yes — veterans commonly file Tinnitus secondary to TBI / Traumatic Brain Injury, Hearing Loss under 38 C.F.R. § 3.310. In a secondary claim, the nexus letter's job changes: instead of connecting Tinnitus to service directly, it explains the medical mechanism by which the service-connected condition caused or aggravated it.
What does a tinnitus nexus letter example look like?
It states the diagnosis (recurrent tinnitus), the opinion at the "at least as likely as not" standard, the records the clinician reviewed, your account of when the ringing started, and a rationale: the specific noise exposure, why a normal separation hearing test doesn't rule tinnitus out, and why other causes don't account for it. The sample wording on this page shows that structure for an invented veteran.
Do I need a nexus letter for tinnitus?
Not always. VA's own examiner often gives the opinion, especially when your duties involved noise VA recognizes. A private opinion matters most when the VA exam was negative, for example when it rested only on a normal hearing test at separation.
Can tinnitus be service-connected without hearing loss?
Yes. Tinnitus is rated as its own condition under DC 6260, and it can be service-connected whether or not you have measurable hearing loss. The nexus letter should explain why noise exposure can cause tinnitus even with a normal audiogram.
How much is tinnitus rated?
A single 10 percent under 38 C.F.R. § 4.87, DC 6260, whether the sound is in one ear, both ears, or in the head. That is the maximum for tinnitus on its own.