Citation Nr: 18146578 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-03 592 DATE: October 31, 2018 ORDER Service connection for gastroesophageal reflux disease (GERD) is granted. FINDING OF FACT The Veteran’s GERD is proximately due to his service service-connected disability of migraine headaches. CONCLUSION OF LAW The criteria for entitlement to secondary service-connection for GERD have been met. 38 U.S.C. § 1110 (2018); 38 C.F.R. § 3.310(a) (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 2000 to July 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision of the VA Regional Office (RO) in St. Paul, Minnesota. In October 2015, the Board remanded the case to the RO to issue the Statement of the Case (SOC) which was issued in December 2015. In July 2016, the Veteran appeared at the RO in Louisville, Kentucky, for a hearing via videoconference before the undersigned and the hearing transcript has been associated with the Veteran’s claims file. At the hearing, the Veteran requested to keep the record open so he could supplement it with a private medical opinion. The Veteran timely submitted that evidence and then waived the Agency of Original Jurisdiction (AOJ) review. 1. GERD Factual Background Service connection is in effect for migraine headaches. The Veteran contends that he has GERD resulting from the pain medications used for his service-connected migraine headaches. The evidence of record includes the report of a February 2015 VA examination, VA medical treatment records, private medical treatment records received in July 2013 from Dr. S., a letter dated in April 2013 and signed by Dr. S. referencing Veteran’s medications, a 2015 pharmacological reference article listing and discussing side effects of Veteran’s medications, a July 2016 private medical examination report prepared and signed by Dr. L., Pharm. D., and the transcript of the July 2016 Board testimony. The April 2013 letter signed by the Veteran’s family physician and primary care provider, Dr. S., , lists the Veteran’s pain medications to include triptans, Amitriptyline, Topamax, Depakote, and Excedrin “taken on a very frequent basis.” The February 2015 VA medical report reflects that the VA examiner conducted the examination using the Acceptable Clinical Evidence (ACE) process without examining or interviewing the Veteran. The report further reflects that the examiner reviewed the claims file and opined that GERD is less likely than not proximately due to or the result of the Veteran’s service connected condition. In support of this opinion, the examiner stated that the Veteran is taking Maxalt, Elavil, Botox, and several OTC medications (CoQ, Magnesium, feverfew) for his headaches and none of these medications would cause or aggravate his GERD. The VA medical treatment records reflect the Veteran’s list of medications to include Naproxen, Rizatriptan, Amitriptyline, Excedrin, Topamax, Imitrex, Gabapentin, Co-q10, Magnesium, Feverfew, Melatonin, Elavil, Botox, Methylprednisolone, Inderal, and Omeprazole (for GERD). The private medical report, dated July 2016 and signed by Dr. L., shows that Dr. L. interviewed the Veteran, reviewed the Veteran’s medical history including his medications and underlying conditions, then evaluated Veteran’s lifestyle behaviors that may negatively influence or promote heartburn or GERD. Dr. L. found that none of the underlying medical conditions or negative factors that would potentiate heartburn or GERD are present. Upon comprehensive review of the gathered information, Dr. L. identified the four particular medications that the Veteran has been taking have documented reports of causing or being associated with heartburn and/or GERD, including Naproxen, Meloxicam, Etodolac, and Rizatriptan. Dr. L., relying on statistical clinical data provided by Clinical Pharmacology and discussing it at some length, opined that the Veteran’s heartburn symptoms and GERD were likely initiated and then worsened through the initial and continued use of the referenced medications. Dr. L, explained that to investigate the correlation and causality, he referenced a “trusted and frequently utilized resource,” Clinical Pharmacology. Upon closer assessment of the documented adverse effects, Dr. L. found the Veteran’s medications to be correlated and resulting in the potential for heartburn and GERD. Dr. L. further explained that, for example, Naproxen has been documented as having a 3-9% chance of causing heartburn and many other gastrointestinal related events. Meloxicam has been documented as having about 2% chance of GERD along with many other serious and non-serious gastrointestinal related events. Dr. L. reasoned that these documented associations along with the corresponding medical history of the Veteran provide enough evidence to conclude that they may be related to the Veteran’s current distressed state coping with his documented history of GERD. Dr. L. concluded that the Veteran’s heartburn symptoms and GERD were likely initiated and then worsened through the initial and continued use of the referenced medications. At the July 2016 hearing, the Veteran asserted that the VA examiner did not examine or interview him, did not identify any data based on which the conclusion was reached, while relying on inaccurate facts, performing only a cursory review of the records, and only considering a snapshot of the medication that the Veteran was taking at that moment of the examination and opinion. The Veteran further testified that he has been taking medication for his service-connected disability of migraine headaches for over a decade. The list of those medications includes but is not limited to Imitrex, Gabapentin, Topamax, Amitriptyline, Prednisone, Promethazine, Rizatriptan, Naproxen, and Excedrin. According to the Veteran, many of these medications have known side effects such as gastroenteritis, gastroesophageal reflux disease, hiatal hernia, dyspepsia, and stomach problems. In July 2015, as part of the original claim, the Veteran submitted a pharmacological reference article from Clinical Pharmacology listing pertinent medications and the corresponding relevant side effects. At the hearing, the Veteran then argued that the VA examiner considered neither the length of time that the Veteran has been taking all these medications nor the cumulative effect of taking these medications for over a decade. The Veteran emphasized that the examiner conducted a snapshot view of his medications and did not speak to him at all. The Veteran further testified that shortly after experiencing a near bomb blast in Iraq his service-connected migraine headaches had started and he started heavily self-medicating with Excedrin, which he continued to use for a couple of years. This is when the Veteran began to take Excedrin “like it was Tic Tacs” and “that’s when the heartburn started.” Then, the Veteran started taking Depakote and Naproxen which aggravated the symptoms. According to the Veteran, both the VA and private medical treatment records show that the Veteran has been continuously taking just Naproxen alone for at least a decade. The Veteran could not pinpoint a precise time of when he first experienced the heartburn symptoms, the VA eventually recognized GERD and placed the Veteran on Omeprazole to treat his GERD symptoms. The Veteran also testified that he has never experienced heartburn in his life prior to entering service and beginning medications for his service-connected migraine headaches. Legal Principles Service connection may be granted on secondary basis for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was proximately caused by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Once the evidence has been assembled, the Board must evaluate all lay and all medical evidence. 38 U.S.C. § 7104(a). In evaluating the evidence, the Board must consider the competence, credibility, and probative value of each piece of the evidence. Among considerations is the adequacy of the medical opinions. When the VA undertakes to provide a VA medical examination or to obtain a VA opinion, the VA must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). It is the Board’s duty to assess the credibility and weight to be given the evidence. Wilson v. Derwinski, 2 Vet. App. 614, 618 (U.S. 1992). Between the two differing medical opinions, the Board is free to assess each piece of medical evidence and is not compelled to accept a private medical opinion over the VA medical examiner’s opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). The converse is also true, whereas the Board is not compelled to accept the VA examiner’s opinion over a private medical opinion and the inquiry must focus on the quality of an opinion. Discussion The Board finds that criteria for service connection on a secondary basis for GERD have been met in this case. Secondary service connection requires evidence showing that a claimed disability exists and that it was proximately caused by a service-connected disability. Both of those requirements are satisfied in this case. The Board notes that the existence of GERD has been conceded by the VA and the two independent private medical providers and thus is not at issue here. GERD is further evidenced in the Veteran’s detailed testimony that is supported by a long-documented history of pertinent complaints and symptoms as well as by an Omeprazole prescription regularly issued by the VA to treat GERD symptoms. Thus, the Board turns its analysis to the proximate causation. Concerning the proximate cause in this case, the evidence of record reflects two opposing medical opinions, the negative VA medical examiner’s opinion and the positive medical opinion of a private provider. On the one hand, the private medical opinion is provided by a licensed pharmacological specialist, based on accurate facts, includes a thorough and comprehensive review of the Veteran’s medical history and records, and provides fully articulated sound reasoning for the conclusion supported by sufficient data. Accordingly, the Board assigns this medical opinion a significant probative weight. On the other hand, the Board finds that the VA examiner’s medical opinion is inadequate because it is based on incomplete factual information. In April 2013 letter from Dr. S., the list of Veteran’s pain medications includes triptans, Amitriptyline, Topamax, Depakote, and Excedrin “taken on a very frequent basis.” Supported by the VA medical treatment records, the Dr. S.’s letter corroborates both the Veteran’s testimony and Dr. L.’s opinion. This letter also strengths the Veteran’s argument concerning the inadequacy of the VA medical examiner’s examination and opinion. The letter further undermines the credibility of the VA examiner’s opinion because that opinion is based only on “Maxalt, Elavil, Botox, and several OTC medications (CoQ, Magnesium, feverfew).” Further, the VA records available to the VA examiner at the time of the examination list the Veteran’s medications to include Rizatriptan, Naproxen, Imitrex, Gabapentin, Topamax, Amitriptyline, Prednisone, Promethazine, Excedrin, and Omeprazole. These medications, however, were not considered as part of the opinion rendered by the VA examiner. It follows that the conclusion in the VA medical opinion is based on incomplete factual information, which on its own suffices to accord such an opinion little to no probative value. Accordingly, the Board finds that the Veteran’s GERD is at least as likely as not proximately due to the side effects of the pain medications the Veteran has been taking for his service-connected disability of migraine headaches and therefore the secondary service connection for GERD is granted. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Bardin, Associate Counsel