Stefl v. Nicholson

21 Vet. App. 120 (2007), decided March 27, 2007. Court of Appeals for Veterans Claims, No. 04-2192, Judge Lance; Chief Judge Greene dissenting. Precedential. Board decision vacated and remanded.

Two holdings, both of which get cited constantly, and the second one is the sentence most often quoted about VA examinations.

Holding one: a presumption is not a ceiling

Mr. Stefl served in Vietnam and developed nasal polyps with atypical squamous metaplasia — a condition not on the herbicide presumptive list at 38 C.F.R. §3.309(e). The VA examiner reasoned: the condition is not on the list, therefore it "is not related to service or exposure to Agent Orange."

The court held that reasoning inadequate on its face. A presumption exists because Congress directed the Secretary to recognize conditions where a "positive association" has been established by the scientific record. That a condition has not yet made the list says nothing about whether this veteran's exposure caused this disease. In the court's words: "The availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange." The Secretary conceded the point.

So: a medical nexus opinion that denies a link because the condition is not on a presumptive list, without clearly considering direct service connection, is inadequate. If an examiner's whole rationale is "not on the list," the opinion has not answered the question that was asked.

Holding two: the conclusion needs the reasoning attached

The court then said what makes an opinion usable at all. An opinion is adequate where it is "based upon consideration of the veteran's prior medical history and examinations and also describes the disability ... in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." But beyond that:

"Not only must the medical opinion clearly consider direct service connection, it must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."

And the line that gets quoted: "a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion."

The reason is structural rather than fussy. The Board is not allowed to supply medical reasoning of its own — that rule comes from Colvin v. Derwinski. So an opinion with a conclusion and no analysis leaves the Board with nothing it is permitted to do.

The court offered examples of what an opinion can usefully discuss — why cited studies are or are not persuasive, whether the veteran has other risk factors, whether the condition has presented unusually — while saying expressly that the list is neither exclusive nor required. It is illustrative, not a form to fill in.

What it does not hold

It does not tell examiners how to write opinions, and the majority says so directly: "the majority's opinion does not dictate how a medical opinion should be formulated." Chief Judge Greene dissented on exactly this, reading the examiner's sentence as containing a direct-service-connection opinion and arguing that the Board had a plausible basis to rely on it, and that the majority "stretches the boundaries of our review."

It also does not mean a short opinion is a bad one. The requirement is reasoning, not length.

Where this leads

Stefl sets the floor; Nieves-Rodriguez builds on it a year later, holding that most of an opinion's probative value comes from its reasoning rather than from whose letterhead it is on. Together they are the two cases to read before asking a clinician for a medical opinion.

Finding the opinion

The court's official PDF: Stefl_04-2192.pdf. Published at 21 Vet. App. 120.

Reviewed October 6, 2026