How VA Disability Ratings Work in 2026: Secondary Conditions, Nexus Opinions, PACT Act and the C&P Exam

You filed your claim. VA gave you 30%, maybe 50%. But you're still waking up at 3 a.m., still skipping social events because of your symptoms, still paying out of pocket for conditions that started in service. The rating doesn't seem to match your life.

This article explains how the rules behind a rating work: secondary service connection, nexus opinions, the PACT Act presumptions, review options after a decision, combined ratings math and the C&P exam. It is education, not legal advice. For decisions on your claim, work with an accredited representative: a VSO representative, accredited claims agent or VA-accredited attorney. VSO help is free.

VA Secondary Conditions for PTSD and TBI

A secondary condition is one that is "proximately due to or the result of" a service-connected condition, or that a service-connected condition made worse. IAW 38 CFR 3.310(a), that disability "shall be considered a part of the original condition." You don't need a new in-service event. VA looks for medical evidence linking the secondary condition to the primary one.

Conditions often claimed as secondary, organized by primary diagnosis:

PTSD:

• Sleep apnea
• Hypertension
• Gastroesophageal reflux disease (GERD)
• Erectile dysfunction (often discussed in connection with PTSD medications)
• Migraines

TBI:

• Depression and cognitive symptoms
• Sleep disturbances and insomnia
• Headaches
• Tinnitus (especially after blast exposure)
• Hormonal deficiencies

Chronic pain and musculoskeletal conditions:

• Depression
• Conditions linked to documented immobility from a service-connected injury

Being on a list does not make a connection. Each one turns on the medical evidence in your own file. Talk through any possible secondary condition with your accredited representative.

What a Nexus Opinion Addresses

A nexus opinion is a written medical opinion about whether a condition is connected to service (or to another service-connected condition). VA weighs it with the rest of the evidence. VA can also get its own medical opinion when the file needs one (38 CFR 3.159(c)(4)).

The standard of proof is often written as "at least as likely as not," meaning a 50% or greater probability. No exact wording is legally required. VA looks at what the opinion concludes and, above all, at the reasoning behind it.

What a well-supported opinion usually contains:

• The provider's credentials
• What records the provider reviewed
• The specific diagnosis being discussed
• A clear conclusion about the connection, in the provider's own words
• A rationale explaining the medical basis for the conclusion

Common weaknesses VA points to:

• Speculative language such as "may be related" or "could be connected"
• No statement of what records were reviewed
• A conclusion with no rationale

Your provider writes the opinion. Ask your accredited representative whether your file needs one.

PACT Act Presumptive Conditions

The PACT Act, signed August 10, 2022, created presumptions of exposure and of service connection for many toxic-exposure conditions. Presumptive means VA presumes the service connection when the rule's conditions are met, so you generally do not need a medical nexus opinion linking the condition to service.

Key presumptive categories:

• Burn pits and other airborne hazards (Gulf War and post-9/11): Asthma diagnosed after service, chronic sinusitis, chronic rhinitis, constrictive bronchiolitis, COPD and a list of cancers in 38 U.S.C. 1120(b). If you served in a covered location in 38 U.S.C. 1119(c) (on or after August 2, 1990 for the Gulf countries and Somalia, on or after September 11, 2001 for Afghanistan and the others listed), you are presumed exposed.
• Two newer rules, January 2025: VA added 38 CFR 3.320a for bladder, ureter and related genitourinary cancers (90 FR 23, January 2, 2025) and 38 CFR 3.320b for leukemias, multiple myeloma, myelodysplastic syndromes and myelofibrosis (90 FR 1894, January 10, 2025), both tied to fine particulate matter exposure.
• Camp Lejeune contaminated water (1953 to 1987): 8 presumptive diseases under 38 CFR 3.309(f), not the PACT Act, including bladder cancer, kidney cancer, non-Hodgkin's lymphoma, Parkinson's disease and adult leukemia.
• Radiation exposure: Certain cancers for veterans who took part in atmospheric nuclear testing or the occupation of Hiroshima or Nagasaki.

The forms involved: a condition never claimed before goes on an initial claim (VA Form 21-526EZ). A condition VA already denied can be looked at again through a Supplemental Claim (VA Form 20-0995), which needs new and relevant evidence. Ask your accredited representative which applies to you.

On effective dates: IAW 38 CFR 3.114, a benefit granted under a liberalizing law can be paid from the law's effective date if your request is "received within 1 year from that date." Filed later, payment can reach back "1 year prior to the date of receipt of such request." It does not automatically reach an older denied claim.

Review Options After a Denial

A denial is a decision you can have reviewed. Under the Appeals Modernization Act there are three lanes:

• Supplemental Claim (VA Form 20-0995): for new and relevant evidence VA did not have before.
• Higher-Level Review (VA Form 20-0996): a senior reviewer looks at the same evidence for an error. No new evidence.
• Board appeal (VA Form 10182, Notice of Disagreement): an appeal of the decision to the Board of Veterans' Appeals.

Things to understand about your decision letter:

• The "Reasons for Decision" section says what VA found missing or weighed against the claim
• A denial usually turns on diagnosis, in-service event, nexus or severity
• A Supplemental Claim without new and relevant evidence will not be readjudicated (38 CFR 3.2501)
• You can request a copy of your claims file (C-file) to see what VA already has

Which lane fits your decision is a question to take to your accredited representative.

How Combined Ratings Are Calculated

VA does not add ratings together. It combines them with the table in 38 CFR 4.25, applying each rating to the "efficiency" left over. The order is fixed by the rule, highest rating first, so there is no filing order or combination that changes the math.

If you have a 50% rating, the table treats you as 50% disabled and 50% efficient. A second 30% rating applies to that remaining 50%, adding 15 points. That gives 65, which rounds to 70% (IAW 38 CFR 4.25, "combined values ending in 5 will be adjusted upward").

Two rules worth knowing:

• A 100% rating: IAW 38 CFR 3.350(i), a single 100% disability plus other disabilities "independently ratable at 60 percent" can qualify for SMC-S. Other ratings do not add to a 100% combined rating.
• The bilateral factor: for compensable disabilities of both arms, both legs, or paired skeletal muscles (like both knees; hearing loss does not count), IAW 38 CFR 4.26, 10 percent of the combined value of the two sides is added before the rest of the combination.

Worked example of the table: A veteran with a combined value of 70 is granted a 50% rating and a 20% rating. On the 4.25 table, 70 and 50 combine to 85, and 85 and 20 combine to 88, which rounds to 90%. At the rates effective December 1, 2025, the difference between 70% and 90% for a veteran with no dependents is $553.85 a month. Every rating depends on the evidence and the rating criteria. This example shows the math, not a likely result.

C&P Exam Preparation

Many veterans underreport at the Compensation and Pension exam. Years of conditioning (push through the pain, don't complain, others have it worse) lead veterans to describe their best day and leave the flare-ups out.

IAW 38 CFR 4.1, ratings represent "the average impairment in earning capacity," and the schedule accounts for "considerable loss of working time from exacerbations." VA does not rate your worst day. It rates the average over time, and your flare-ups are part of that average.

What helps veterans describe their condition accurately:

• Read the DBQ (Disability Benefits Questionnaire) for your condition. These are public forms. They show what the examiner is assessing.
• Think through how the condition affects you over time. How often flare-ups happen, how long they last, and what you cannot do during them.
• Describe frequency as well as severity. Daily, weekly or monthly.
• Be accurate, not minimal. "I push through" can be recorded as no limitation. Describe what you actually cannot do without help or medication.
• Bring a list of the medications you take for the condition.

If you think an exam was inadequate, you can tell VA in writing, and your accredited representative can explain your options. A Notice of Disagreement appeals a decision to the Board. It is not filed against an exam. After a decision, the review lanes above are how you challenge how the evidence, including the exam, was weighed.

Five Topics to Understand Before You Meet Your Representative

Your conditions. A complete list of every diagnosed physical and mental health condition, rated or not, compared with the PACT Act presumptive list and possible secondary connections.

The connection. For each condition, which pathway the rules describe: direct, secondary or presumptive, and whether the file has the medical evidence that pathway needs.

Your evidence. Service records, medical records and opinions, buddy statements and your own lay statement.

Your exam. How each condition affects you over time, flare-ups included, so you can describe it accurately.

The math. How 38 CFR 4.25 combines ratings, so you can read your decision letter.

Want the Full Guide?

The VA Disability Claim Blueprint is a $27 PDF that goes deeper on each topic above: a secondary conditions map organized by primary diagnosis, sample nexus opinion outlines, a PACT Act presumptive conditions checklist with the regulation behind each presumption, a C&P exam prep checklist, and a combined ratings worksheet.

It is education, not legal advice or representation, and it does not promise any rating. For your claim, work with an accredited VSO representative, claims agent or VA-accredited attorney. VSO help is free.

Get The VA Disability Claim Blueprint · $27