Citation Nr: 1336805 Decision Date: 11/13/13 Archive Date: 11/26/13 DOCKET NO. 10-29 653 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a gastrointestinal disorder, including erosive duodenitis and gastroesophageal reflux disease, and to include as secondary to service-connected depression. 3. Entitlement to a rating in excess of 10 percent for the service-connected low back strain. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from August 1998 to August 2000. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the RO. On a VA Form 9, Appeal to the Board, dated in July 2010 and in connection with a subsequent August 2010 Report of Contact, the Veteran expressed her intention to withdraw the claim for an increased rating for the service-connected depression from appellate review. Thus, this matter is no longer before the Board. A review of the Veteran's Virtual VA and VBMS electronic claims file reveals no additional records. The issue of service connection for a gastrointestinal disorder is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The currently demonstrated chronic hypertension is shown as likely as not to have been manifested to a compensable degree during the first year after the Veteran's period of active service. 2. The service-connected low back strain is shown to have been productive of a disability manifested by complaints of pain on motion, but a limitation of flexion to 60 degrees or less, a combined range of motion of the thoracolumbar spine to 120 degrees or less; a finding of muscle spasm, guarding, or localized tenderness severe enough to result in abnormal gait or abnormal spinal contour; a finding of a separately ratable neurologic impairment; or a finding of incapacitating episodes is not demonstrated. CONCLUSIONS OF LAW 1. By extending benefit of the doubt to the Veteran, his disability manifested by hypertension is presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102 , 3.307, 3.309 (2013). 2. The criteria for the assignment of a rating in excess of 10 percent rating for the service-connected low back strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a including Diagnostic Code 5237 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Given the favorable disposition of the claim for service connection for hypertension, the Board finds that a full discussion of VCAA is not required at this time. As regards the claim for increased rating for the service-connected low back strain, under VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a February 2009 pre- rating letter, the RO notified the Veteran of the evidence needed to substantiate the claim for increase. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran has substantiated his status as a veteran. The Veteran was notified of all other elements of Dingess in the February 2009 letter. The Board further finds that VA has complied with the duty to assist by aiding the Veteran in obtaining evidence. Here, VA obtained the Veteran's service treatment records and all of the identified post-service non-VA and VA treatment records. The Veteran was also afforded VA examinations in July 2009 and February 2012 in order to evaluate the severity of the service-connected low back disability. As these examinations were based on review of the Veteran's symptoms and complaints and discussed his low back disability in relation to the pertinent rating criteria, they are adequate for adjudication purposes. For these reasons, the Board finds that VA has complied with the VCAA's notification and assistance requirements. II. Service Connection for Hypertension As an initial matter, the Board notes that the Veteran did not engage in combat with the enemy. Therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2002) are not applicable. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for chronic disease such as hypertension, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In order for hypertension to be considered manifested to a compensable degree, the evidence must show diastolic pressure of predominantly 100 or more, or; systolic pressure of 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. See 38 C.F.R. § 4.104, Diagnostic Code 7101. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The service treatment records show numerous blood pressure readings; however, there is no indication of a diagnosis of hypertension in service. On VA examination in September 2000, one month following the Veteran's discharge from service, his sitting blood pressure was 144/100, recumbent blood pressure was 140/98, and standing blood pressure was 158/110. The Veteran indicated that he was given blood pressure medication in service. A November 2000 report from the Diagnostic Clinic of Longview noted the Veteran's past medical history of slight high blood pressure. A January 2001 report added that the Veteran was taking medication for his blood pressure. The VA outpatient treatment records note a diagnosis of hypertension in February 2008. It was reported that he had been on numerous blood pressure medications in the past. A December 2009 statement from a nurse practitioner noted that the Veteran was on blood pressure medication for his hypertension. She expressed her opinion that the hypertension was stress-induced. On VA examination in July 2011, the examiner noted that the Veteran's service treatment records did not show any indication of sustained elevation of blood pressure and that there was no diagnosis of hypertension while in service. However, the VA examiner added that the VA examination shortly after his discharge showed three elevated blood pressures. The Veteran also was noted to have reported that he was referred to a cardiologist after the VA examination and started on Atenolol for hypertension. The Veteran indicated that the cardiologist also performed a work-up including exercise tolerance test, echocardiogram and heart catheterization. On examination, blood pressure readings were 163/89 on the left arm, and 182/85 on the right arm. The Veteran indicated that he was now taking Benicar for his high blood pressure. An impression of essential hypertension was recorded. The VA examiner noted that, while the service treatment records did not support a diagnosis of hypertension, the Veteran did develop hypertension and begin treatment within one year of discharge from service. In an October 2011 statement, the Veteran reported being referred to a cardiologist following the September 2000 VA examination and being diagnosed him with hypertension and prescribed medication in December 2000. He indicated that he had required the use of medication to control his hypertension since that time. Based on this record, the Board finds the evidence to be in relative equipoise in showing that current hypertension was initially manifested to a compensable degree within one year of the Veteran's discharge from service. The July 2011 examiner specifically indicated that the Veteran's hypertension developed within one year of service. The examiner noted the pertinent history, reviewed all medical records and provided a reasoned analysis of the case. See Hernandez-Toyens, 11 Vet. App. at 383; Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994) (the probative value of a physician's opinion depends in part on the reasoning employed by the physician and whether or not (or the extent to which) he reviewed prior clinical records and other evidence). His opinion is consistent with the Veteran's medical records as well as the Veteran's statements regarding his medical history. Moreover, the VA examination dated one month after the Veteran's discharge from service includes 3 blood pressure readings with diastolic pressure measurements of 100 or more. Private treatment records reflect that the Veteran began taking medication for control of his blood pressure by January 2001. In resolving all reasonable doubt in the Veteran's favor, service connection is warranted. III. Increased Rating for Low Back Strain Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). In this case, the disability has not significantly changed and uniform evaluations are warranted. In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. The service-connected low back strain is rated as 10 percent disabling under the criteria of 38 C.F.R. § 4.71a including Diagnostic Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. A 10 percent disability rating is assigned for incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, with higher evaluations for incapacitating episodes of increased duration. Note 1 states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note 2 indicates that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, the rater is to evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. An August 2008 x-ray study of the Veteran's lumbar spine showed a lordotic curve that was slightly accentuated diffusely. Except for a slight curvature change, the study was normal. An MRI revealed findings of very early mild degenerative disc change at the L4-5 disc level with no focal disc herniation. On VA examination in July 2009, the Veteran reported having continued low back pain rated at a level of 4 on a scale to 10. He indicated that the pain increased to a level of 9 with activity. The pain did not radiate. He did not wear a brace. He had had an epidural steroid injection on one occasion in 2004 that gave him temporary benefits lasting 3 weeks. He currently took Celebrex and Hydrocondone for treatment. The Veteran indicated that his symptoms had gradually worsened. The examiner noted that lumbar MRI's in 2005 and in November 2008 showed degenerative disc disease. The examination showed a positive straight leg raising sign on the right at 85 degrees and on the left at 90 degrees. Sensation to pinprick and vibratory stimulation of the feet were normal. Flexion was performed to 95 degrees; extension was performed to 30 degrees, and lateral and rotary movements were performed to 30 degrees on the right and the left. While range of motion was painful, it remained unchanged after repetitive motion. The examiner also noted that symptoms of pain, weakness, excess fatigability, or incoordination were not further evident on repetitive movement. Paraspinous muscle tone was normal. There was no scoliosis, and his gait and lumbar curve were normal. A diagnosis of degenerative disc disease of the lumbar spine with back pain, without radiation, was recorded. The examiner indicated that the disability was moderate with subjective progression. His job stocking parts at an Army depot was noted to aggravate his lumbar spine. The examiner noted that there had been no incapacitation over the last year regarding the lumbar spine. The VA outpatient treatment records also reflect the Veteran's complaints of chronic low back pain. In September 2009, the Veteran presented with chronic low back pain and L4-5 small disc protrusion. The pain was noted to be worse with movement and prolonged sitting, or standing. He was able to work in supply. He did not have bladder or bowel incontinence. He also endorsed some numbness and pain on the right side of his leg. A diagnosis of lumbar spine degenerative disc disease was recorded. In January 2011, the Veteran presented with complaint of low back and right thigh pain with flare-ups of pain once daily. He reported having pain that was constant and aggravated by sitting, standing, walking or quick movements. Alleviating factors included prescribed medications of Lortab and Tramadol. An April 2011 VA MRI report noted multilevel lumbar spondylotic changes. Interval progression was suggested at L2-3 and L4-5. On VA examination in February 2012, the Veteran complained of having low back pain radiating down the right leg and right lateral thigh numbness. He denied any intervening trauma and stated that he had missed 21 days of work during the previous year due to back pain. The Veteran denied experiencing flare-ups of pain. The range of motion testing revealed that flexion was performed to 85 degrees with no objective evidence of painful motion. Extension was performed to 30 degrees or greater also with no objective evidence of painful motion. Right and left lateral flexion and right and left lateral rotation were to 30 degrees or greater with no objective evidence of painful motion. Repetitive range of motion testing resulted in no additional limitation of motion in degree. The examiner determined that the Veteran did not have any functional loss or functional impairment involving the lumbar spine. On examination, there was no localized tenderness or pain to palpation of the joints or soft tissue of the thoracolumbar spine. There was no guarding or muscle spasm of the lumbar spine. The Veteran did not use any assistive devices for walking. The muscle strength testing of the lower extremities yielded normal findings, and there was no muscle atrophy. The reflex and sensory examinations were also noted to be normal. A straight leg raising test was negative on the right and left. The examiner determined that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. He also noted that there were no other neurologic abnormalities or findings related to the thoracolumbar spine, such as bowel or bladder problems. The nerve conduction studies of the bilateral lower extremities were also noted to be normal. Finally, the examiner determined that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. The examiner added that the back disability impacted his ability to work, in that the Veteran missed 21 days of work in the previous 12 months due to his back. It was noted that the Veteran was employed at an Army depot. The examiner diagnosed lumbar spondylosis secondary to a 2004 intervening injury. In so finding, the VA examiner added that a review of the medical records reflected that the Veteran was treated for lumbar strain in 1999 in service due to weight lifting, but had no further complaints of pain until after further lifting heavy weights in 2004. After that date, he had numerous consultations and MRIs that indicated an anatomical problem at L4-5. The records were further noted to reflect that the Veteran continued to lift weight or carry heavy objects and aggravated his back problems following a 2009 lifting incident and again in March 2011. A peripheral nerve examination conducted in conjunction with the lumbar spine examination yielded normal nerve conduction studies. After complete neurological examination, the examiner determined that there was no evidence of a right lower extremity radiculopathy, despite the Veteran's complaints of moderate intermittent pain in the right lower extremity. The service-connected low back strain is assigned a 10 percent rating that is consistent with painful motion of the thoracolumbar spine. 38 C.F.R. § 4.59. It is also consistent with a rating for a thoracolumbar spine disability manifested by forward flexion limited to less than 85 degrees but greater than 60 degrees; a combined range of motion of the thoracolumbar spine that was less than 235 degrees but greater than 120 degrees; a finding of muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or a finding of a vertebral body fracture with loss of 50 percent or more of height. In order to warrant a higher rating in this case, there must a disability picture manifested actual limitation or a functional equivalent of flexion restricted to 60 degrees or less, but greater than 30 degrees; a combined range of motion of the thoracolumbar spine to 120 degrees or less; or a finding of muscle spasm, guarding, or localized tenderness severe enough to result in abnormal gait or abnormal spinal contour. See DeLuca, supra; 38 C.F.R. § 4.7. In this case, however, a limitation or functional equivalent of flexion restricted to 60 degrees or less; a combined range of motion to 120 degrees or less; or an abnormal gait or abnormal spinal contour due to muscle spasm, guarding, or localized tenderness is not demonstrated. In addition, as noted, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, the examiners specifically found that repetition on the range of motion three times did not increase any of these symptoms. Consequently, a higher rating is not warranted on this basis. Separate ratings for associated objective neurologic abnormalities or chronic neurologic manifestations are not warranted because neurologic findings and symptoms warranting separate ratings have not been demonstrated. The Board is fully aware of the Veteran's assertions of pain radiating down the right lower extremity. However, the VA neurologic examinations have yielded normal findings, and the February 2012 examiner specifically indicated that there was no evidence to support a diagnosis of radiculopathy. In the absence of demonstrated neurologic impairment, there is no basis to assign a separate, compensable rating in this case. Accordingly, a separate evaluation for neurologic manifestations is not warranted. The Board has considered other appropriate diagnostic codes, particularly Diagnostic Code 5243 Intervertebral Disc Syndrome. However, there is no showing of incapacitating episodes as contemplated by the regulation. While the Veteran reports having periods where he cannot perform certain functions due to back pain and missing some days from work during previous year due to his back, neither the lay assertions nor the medical evidence shows that there has been physician-prescribed bed rest. In the absence of such findings or lay assertions of intervertebral disc syndrome, the criteria for rating incapacitating episodes are not applicable. The Board has also considered the Veteran's statements regarding the severity of his low back symptoms. Certainly, as a lay person, the Veteran is competent to attest to physical symptoms that he experiences, such as persistent low back pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, neither the medical evidence nor the lay evidence of record suggests that an evaluation in excess of 10 percent is warranted at this time. His statements were non-specific and failed to establish a greater degree of functional impairment warranting a higher rating. Here, the medical findings (as provided in the July 2009 VA and February 2012 examination reports) directly address the criteria under which the low back disability is evaluated. The medical evidence are found to be far more probative weight than his lay statements. As to consideration of an extraschedular rating, this requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. All potentially relevant rating codes have been considered and evaluated. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is therefore not required. In any event, the Veteran does not claim, nor does the evidence reflect, that there is marked interference with employment or frequent hospitalization so as to render impractical the application of the regular schedular standards. Here, the level of impairment is reasonably contemplated by the disability evaluation assigned in accordance with established criteria. Therefore, referral for consideration of an extraschedular rating is not warranted. 38 C.F.R. § 3.321(b)(1). For the foregoing reasons, the Board concludes that there is no basis for staged ratings of the service-connected low back strain, as his symptoms have been primarily the same throughout the appeal period and finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent. See 38 U.S.C.A. § 5107(b) ; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for hypertension is granted. An increased rating in excess of 10 percent for the service-connected low back strain is denied. REMAND The Veteran also is seeking service connection for a gastrointestinal disorder, to include erosive duodenitis and gastroesophageal reflux disease (GERD), that he believes had its onset in service or, in the alternative, is secondary to his service-connected depression. In various written statements, the Veteran indicated that he experienced stomach pain while in service and took antacids for relief. He indicated that he was diagnosed with GERD on examination in September 2000, one month following his discharge from service. As noted above, service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The service treatment records do not document diagnosis of GERD, erosive duodenitis, or other related gastrointestinal disorder. However, on VA examination in September 2000, the Veteran reported experiencing indigestion and heartburn every other day, but not taking anything for these symptoms. He also reported experiencing occasional pain above the umbilicus area. After an examination, the examiner diagnosed reflux symptoms. Significantly, an upper gastrointestinal series test revealed findings of gastroesophageal reflux to the mid-esophagus. An October 2002 private treatment report also noted a diagnosis of GERD. A May 2003 private treatment report noted that the Veteran had been experiencing pain in the upper abdomen and substernal distress for several weeks. After undergoing gastric and duodenum biopsies, diagnoses of chronic superficial gastritis and erosive duodenitis were recorded. A December 2009 statement from a nurse practitioner at the Good Shepherd Glenn-Garrett Clinic noted her opinion that the Veteran's duodenitis was stress-induced. The Veteran was afforded an examination in July 2011 to obtain an opinion as to the etiology of any gastrointestinal disorder. The examiner noted that there were no complaints of gastrointestinal problems in service and added that the Veteran had not developed GERD or epigastric pain for years thereafter. The examiner diagnosed GERD and erosive duodenitis diagnosed by scope procedure. He opined that the Veteran's GERD and erosive duodenitis were not related to depression, noting that there was no literature to connect the two conditions. The examiner also pointed out that GERD was caused by a failure of the competency of the lower esophageal sphincter allowing reflux of gastric contents. Thus, the VA examiner failed to address the September 2000 VA examination report documenting GERD within one month of the Veteran's discharge from service. He also did not provide an opinion as to whether the GERD or erosive duodenitis at least as likely as not had its onset in service. Moreover, to the extent that he did not find a relationship between the service-connected depression and his GERD or erosive duodenitis, he failed to address whether the Veteran's service-connected depression aggravated the claimed disorder. Given that the July 2011 examination report is inadequate as it fails to address pertinent evidence or provide complete opinion as to whether the Veteran's claimed gastrointestinal disorder had its onset in service or is caused or aggravated by the service-connected depression, the Board finds that a remand is necessary in order to obtain the requisite opinion. Accordingly, this remaining matter is REMANDED for the following action: 1. The RO should take all indicated action in order to return the claims file to the examiner who provided the July 2011 opinion or a suitable substitute, for clarification as to the following. The entire claims file must be made available to the designated examiner. If an examination is necessary, one should be provided. After reviewing the entire record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that a gastrointestinal disorder, to include GERD or erosive duodenitis, had its clinical onset during the Veteran's period of active service or otherwise is caused or aggravated (permanently increased in severity beyond the natural progress of the condition) by his service-connected depression. If aggravation is found, the examiner should identify the baseline level of severity of the nonservice-connected disability to the extent possible. In providing the requested opinion, the examiner is asked to discuss the significance of the VA examination report reflecting diagnosis of gastroesphogeal reflux within one month of his discharge from service, as well as the December 2009 opinion from the Veteran's treating nurse practitioner regarding a relationship between his erosive duodenitis and his depression. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should clearly so state, and the reasons and bases for the inability to provide the opinion must be included in the examination report. 2. After completing all indicated development, the RO should readjudicate the claim remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs