Nexus Letter for GERD Secondary to NSAIDs

What a Secondary Claim Means Here

Nothing about this claim says the reflux started in service. It says the reflux came out of something the VA has already agreed it owes you for. That is what 38 C.F.R. 3.310 is for, and the operative sentence is short: except as provided in 38 C.F.R. 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.

This claim adds one link to that chain. The service-connected condition is usually a knee, a back, a hip, a shoulder or an ankle. The medication is what your provider prescribed to treat it. The reflux is what the medication is said to have caused or worsened. VA's adjudication manual states the causation test as whether the condition is the result of, or would not have occurred but for, a service-connected disability, and a prescription written for a service-connected condition sits comfortably inside that language.

There is one thing worth saying plainly, because it is the sort of gap a careful reader will look for and not find. VA's adjudication manual has no topic devoted to medication-caused secondary conditions, and no provision anywhere that names anti-inflammatories as a route to one. It does mention these drugs in passing elsewhere, in the section on dry eye syndrome, as one of several possible causes of a different condition, which is a long way from a rule you can cite for reflux. So the theory runs on the general causation language and nothing more specific. That is not a weakness, but it does mean your letter has to do the whole job of building the chain. If a page quotes you a manual section about medication side effects, check what it actually says: the closest thing in the manual is an informed-consent definition that belongs to a different kind of claim entirely.

For the rating explainer and the other routes to a reflux claim, see our page on GERD and VA disability.

New to these documents? Start with our primer on what a nexus letter is.

Caused By It, or Made Worse By It

These are two different claims with two different proofs, and on this particular theory the distinction does more work than it does on most. The mechanism section above points at aggravation. All four grants read in full for this page were decided on causation. You should plead both, and here is why that is not a hedge.

Why both, and in that order

An opinion that answers only whether the medication caused the condition leaves the aggravation question unexamined, and the Board has set VA opinions aside for exactly that omission in other secondary claims. The reverse is also true: leading with aggravation alone concedes that you had reflux first, which may not be your history and which invites a fight over a baseline you might not need.

The practical answer is that a good letter answers both questions explicitly, in the same document, and says which one the writer thinks the record supports. That costs a paragraph and it closes the most common route to a partial denial.

One thing most sources still have wrong

The aggravation regulation still carries a clause telling the rating activity to deduct any increase in severity due to the natural progress of the disease. It is quoted as live law all over the internet, including on pages about this exact claim. VA has stopped applying it.

After Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023), which held that the statute requires a but-for causation standard rather than a stricter one, VA's manual says it will apply the broader standard and will no longer consider natural progress when deciding a claim based on aggravation. The manual's own deduction arithmetic omits it. That change dates from May 2026 and it runs in your favor.

Spicer carries a second consequence that matters here specifically, and it is worth being precise about who said what. The Federal Circuit held that the statute uses but-for causation. It did not use the phrase contributing cause. The Board did: in Citation Nr A25071899, decided August 26, 2025, it read Spicer to mean that a service-connected disability need only be a contributing cause, not the contributing cause, and on that reasoning it granted service connection for reflux secondary to chronic anti-inflammatory use for a service-connected lumbar spine and both knees, over four negative VA opinions. Board decisions are not precedent (38 C.F.R. 20.1303) and that one does not bind anyone deciding your claim. But if your denial says your weight, your diet or a hiatal hernia explains the reflux, the point survives on the statute alone: a harm can have more than one cause, and yours does not have to be the only one.

The baseline, if you are claiming aggravation

The regulation says the baseline is established by medical evidence created before the onset of aggravation, or by the earliest medical evidence created between the onset of aggravation and the evidence establishing the current level. VA's manual adds a route the regulation leaves out: any other credible evidence, including lay evidence, that supports establishment of the baseline. Lay evidence on its own may not be enough, but it can support the baseline and prompt the VA to develop the claim further.

If no baseline can be established, the manual is blunt: no aggravation can be demonstrated and the claim must be denied. Read the next sentence of the manual too, because it is the one that helps you. A claim may only be denied for lack of baseline evidence after VA has fulfilled its duty to assist, and that duty runs to developing the baseline. If your denial says there is no baseline and the file shows VA never went looking for one, that is a ground to raise rather than a closed door. The manual also tells adjudicators not to assume a baseline of zero percent when one cannot be established, which cuts both ways. And there is a quiet piece of good news in the same section. Aggravation is established by any increase in severity, whether or not it produces a higher schedular evaluation, and where the baseline and the current level sit at the same level the manual directs the rater to grant service connection at a noncompensable evaluation. On this code that still protects your effective date and your route to a future increase.

Can You Add Gastritis or an Ulcer On Top?

If anti-inflammatories injured your esophagus, they may well have injured your stomach too, and the stomach evidence is the stronger of the two. So the question of what can be rated alongside what is a live one. The answer has four parts and most of them are counterintuitive.

None of this is a reason to file narrowly. It is a reason to have the letter address each diagnosed condition on its own symptoms, so a rater can see which facet belongs to which code. That is the difference between a claim that combines and a claim that gets collapsed into one evaluation.

The Language the VA Requires

The VA reads these opinions closely, and small differences in wording change how much weight they carry. Be clear about what the 50 percent figure is and is not. The benefit-of-the-doubt rule in 38 U.S.C. 5107(b) and 38 C.F.R. 3.102 works on the record as a whole: when the positive and negative evidence sit in approximate balance, you win. It is not a pass mark that each individual document has to clear. VA asks for opinions phrased as at least as likely as not because that is the wording that puts evidence into the balance. An opinion phrased as a bare possibility will not carry the claim on its own, but it is still evidence, it is still weighed, and a treating provider saying your reflux may be related to the medication can be enough of an indication to trigger VA's duty to give you an examination and an opinion. So it is worth filing rather than withholding.

One caution about a formulation you may see criticized. In Citation Nr A25014545 the Board called a private opinion vague for finding only that the condition was secondary to, related to, and slash or aggravated by the service-connected disabilities. That is a fair warning, but it is not a rule: in Citation Nr A25079771 a private opinion using almost identical wording was given significant probative weight, because it carried a rationale, the records it relied on, and the drugs by name. Read the two together for what they show rather than for a verdict on the phrase. In A25014545 the Board granted the claim, and it never said the private opinion lacked reasoning or gave it lesser weight; it noted the opinion cited studies on NSAIDs as a risk factor, folded it in with the rest of the evidence, and rested the grant on a VA examiner's opinion. So the phrase alone did not decide either case. What the record shows is that the specific opinion carried the weight.

What the Board Has Actually Done With These Claims

Board of Veterans Appeals decisions are public. Five were read in full for this page, four grants and one denial. They were not chosen because they were favorable: one of them was won with no private opinion in the file at all, which is an awkward fact for a page like this one, and it is below. Read the note under each, because what was granted is narrower than it sounds.

Board of Veterans Appeals decisions are not precedent. Under 38 C.F.R. 20.1303, previously issued Board decisions are binding only with regard to the specific case decided, and each case is decided on the basis of its own individual facts. These are illustrations of how evidence was weighed in other veterans' cases. They do not establish VA policy, they do not bind anyone deciding your claim, and they are not a prediction of your outcome. Note also that every grant described here was a grant of service connection, which is entitlement rather than money. The regional office assigns the evaluation afterward, and a noncompensable evaluation is a possible result.

How to File the Secondary Claim

1. 1File on VA Form 21-526EZClaim GERD as secondary, and say what it is secondary to in plain words: secondary to the medication prescribed for the service-connected condition, naming both. Naming the medication route explicitly keeps it open.
2. 2Claim the stomach conditions separately if you have themIf you also carry a diagnosis of gastritis or peptic ulcer disease, claim it by name and describe its own symptoms. Whether the ratings can combine turns on whether the manifestations are distinct.
3. 3Submit the nexus letter and the pharmacy record togetherYou can file first and add evidence later, but on this claim the opinion and the prescription history are one exhibit. Sending them together is what stops an examiner writing that nothing documents your medication use.
4. 4Go to the examIf the VA schedules an Esophageal Conditions DBQ or a C&P examination, attend it. Describe your symptoms accurately, including what the medication does and does not change.
5. 5If you are appealing a denial, use a Supplemental ClaimVA Form 20-0995 is the route when you have new and relevant evidence, and a nexus letter that answers the ground the VA relied on is exactly that.

File sooner rather than later. The date you file usually sets the date benefits start, and a claim you put off is money left behind, even on a code where the first evaluation may be noncompensable.

Who Should Write the Letter, and What It Costs

Any licensed physician can write a nexus letter. The ones the VA takes seriously come from providers who can explain the mechanism and characterize the literature accurately rather than assert a conclusion. Citation Nr A25047055 makes that concrete: two private opinions were submitted in the same case, and the one the Board found had merely recycled the other opinions of record without providing rationale was given minimal weight, while the one that reasoned from the records was given significant probative value.

Your VA provider is not barred from helping, and on this claim the prescriber is a natural person to ask, because the prescriptions are theirs. VHA Directive 1134(3) requires providers, when requested, to assist patients in completing VA and non-VA medical forms and to provide medical statements about the patient's condition and functionality, except where specifically prohibited. In practice many VA providers do not have your service records in front of them and are not positioned to assess causation, which is why an independent opinion from an outside physician is the usual route. It is a practical limit, not a policy ban, so ask first.

Patriot Path physicians write letters built for this exact claim: the prescription record read closely, the mechanism stated the way the evidence supports it rather than the way the internet repeats it, the competing explanations addressed, and the opinion in the language the VA requires, answering both causation and aggravation. One flat fee of $1,500, and the first consultation is free.

For what your VA provider is required to do when you ask, and what to do if they refuse, see our guide to VA Directive 1134.

Not sure who qualifies? See our breakdown of who can write a nexus letter, and what belongs in one in our guide to nexus letter requirements.

See the full scope of our nexus letter services and how the process works.