Citation Nr: 18148105 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 18-07 420 DATE: November 6, 2018 ORDER Entitlement an initial compensable rating for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for onychomycosis is remanded. Entitlement to service connection for a right hand/wrist disability is remanded. Entitlement to service connection for a left hand/wrist disability is remanded. Entitlement to service connection for a gynecological disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. FINDING OF FACT The evidence demonstrates GERD manifested by subjective complaints of intermittent pyrosis and reflux. CONCLUSION OF LAW The criteria for an initial compensable rating for GERD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.20, 4.114, Diagnostic Code 7346 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Marine Corps (USMC) from June 2002 to June 2006. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from February 2017 and April 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Disability Evaluation - GERD The Veteran has asserted that she should have a higher rating for her GERD as her symptoms are worse than those contemplated by the currently assigned noncompensable rating. The Veteran was afforded a VA examination for her GERD in December 2016. At that time, she reported an onset of symptomatology in 2002. She reported that she had a burning feeling before and after she ate, and that the feeling “comes and goes.” She denied taking continuous medication for GERD. She endorsed pyrosis and reflux. The Veteran did not have an esophageal stricture, spasm, or an acquired diverticulum of the esophagus. The examiner did not find any other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran’s GERD. The examiner found that the Veteran’s GERD did not impact her ability to work. A review of the record shows that the Veteran receives treatment at the VA Medical Center and from private providers for various disabilities, to include her GERD. A review of the treatment notes of record does not show that the Veteran has had symptoms of her GERD that are worse than those reported at her VA examination. The Board finds that assignment of an initial compensable rating for GERD is not warranted based on the evidence currently of record. Here, the evidence shows pyrosis and reflux that was intermittent. There is no indication from the record that the Veteran’s symptoms are persistent. Further, she has reported that she does not use medication to control her GERD symptoms. As such, entitlement to an initial compensable rating for GERD is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7346 (2018). The Board has also considered rating of the Veteran’s GERD under other diagnostic criteria for gastrointestinal disabilities. See 38 C.F.R. § 4.114, Diagnostic Codes 7301-7354. However, the Veteran’s GERD has not been shown to have resulted in any symptomatology which would, in the context of different diagnostic criteria, result in a higher rating. Therefore, the Board finds that the Veteran’s GERD is appropriately rated under 38 C.F.R. § 4.114, Diagnostic Code 7346. Consideration has been given to assigning staged ratings. However, at no time during the period in question has the disability warranted a higher schedular rating than that assigned. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In considering whether a compensable rating is warranted, the Board has considered the benefit-of-the-doubt rule. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. §5107 (b) (2012); Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND The Board finds that additional development is required before the Veteran’s remaining claims on appeal are decided. 1. Service Connection – Low Back, Onychomycosis, Right Hand/Wrist, and Left Hand/Wrist A review of the record indicates the RO has not obtained a complete copy of the Veteran’s service treatment records (STRs). The RO has not drafted a formal finding of unavailability for the record, and did not indicate all efforts to obtain those records have been exhausted and additional attempts would be futile. It appears from the record that the RO merely initiated a single request to the Veteran in an attempt to obtain her STRs. Moreover, a single request was made to the VA Records Management Center (RMC) in an attempt to obtain the Veteran’s STRs. It appears from the record that additional follow-ups were not conducted in an effort to determine whether any additional records could be located following the initial requests. Since the missing STRs could be determinative as to the issues of entitlement to service connection for the above-referenced disabilities, the Board finds additional development to identify and obtain any outstanding records must be accomplished. 2. Service Connection – Gynecological Disability A review of the record shows the Veteran was afforded a VA examination for her gynecological disability in December 2016. However, a review of that examination report shows that the opinion provided is not adequate. The examiner failed to adequately consider the Veteran’s statements regarding the onset and continuity of her symptoms during active service and since. As the opinion is not adequate, the Veteran should be afforded a new VA examination to adequately determine the nature and etiology of any currently present gynecological disability. 3. Disability Rating – Right and Left Ankles The Board notes that in a recent decision the United States Court of Appeals for Veterans Claims (Court) found that 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In other words, if there is not a discussion of those measurements in a VA examination report, the examination is inadequate, unless the examiner determines that those range of motion testing listed could not be conducted. Correia v. McDonald, 28 Vet. App. 158 (2016). A review of the record shows that the Veteran was most recently afforded a VA examination for her bilateral ankle disability in October 2016. A review of those examination reports fails to show findings that are consistent with the holding in Correia. Therefore, the Veteran should be afforded a new VA examination to determine the current level of severity of all impairment resulting from her service-connected bilateral ankle disabilities. The matters are REMANDED for the following action: 1. Request from the National Personnel Record Center (NPRC), or other appropriate source, the Veteran’s complete official military personnel file (OMPF) and service treatment records (STRs) to determine whether any additional service records are available. If any requested records are deemed unavailable, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Also, identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 3. Then, schedule the Veteran for a VA examination by an examiner with sufficient expertise to determine the nature and etiology of any currently present gynecological disability. The examiner should review the claims file and indicate that review in the report. Any indicated studies should be performed. Based upon the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently present gynecological disability is etiologically related to service. In forming the opinion, the examiner must consider the Veteran’s service treatment records indicating complaints of and treatment for abdominal pain, missed menstruation, and sexually transmitted infections during her active service. The rationale for all opinions expressed must be provided. 4. Then, schedule the Veteran for a VA examination by an examiner with sufficient expertise to determine the current level of severity of all impairment resulting from her service-connected right and left ankle disabilities. The claims file must be made available to, and reviewed by the examiner. All indicated tests and studies must be performed. The examiner must provide all information required for rating purposes. In assessing the severity of the right and left ankle disabilities, the examiner should test for pain on both active and passive motion, in weight-bearing and nonweight-bearing. 5. Confirm that the VA examination reports and all opinions provided comport with this remand, and undertake any other development found to be warranted. 6. Then, readjudicate the remaining issues on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mariah N. Sim, Associate Counsel