Citation Nr: 20004828 Decision Date: 01/23/20 Archive Date: 01/21/20 DOCKET NO. 16-63 473 DATE: January 23, 2020 REMANDED Entitlement to an initial compensable evaluation for service-connected hypertension is remanded. Entitlement to service connection for GERD is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from April 1989 to February 1999; October 2004 to November 2005; and August 2010 to September 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2014 and May 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board hearing in October 2019. The Veteran reported at the October 2019 Board hearing that he experiences headaches and symptoms of a cardiovascular condition, which he believes to be associated with his service-connected hypertension. There are no current claims pending for these two issues, and the Board may not raise these on the Veteran’s behalf. Should he desire to apply for secondary service connection for these disabilities, he may submit a formal claim to the RO. 1. Entitlement to an initial compensable evaluation for service-connected hypertension is remanded. The Veteran testified at the October 2019 Board hearing that his hypertension had worsened since the most recent VA examination, which took place in February 2015. Because it appears that the disability has worsened since the last evaluation, a new VA examination is necessary to determine the current severity of the Veteran’s hypertension. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 2. Entitlement to service connection for GERD is remanded. The Veteran testified that he first began experiencing GERD symptoms during service, and on an August 2011 post-deployment health survey, the Veteran indicated that he sought treatment for frequent indigestion and heartburn that continued to bother him after deployment. His service treatment records also reflect a diagnosis of gastritis in August 1991, prior to a hernia repair surgery. Although the Veteran was afforded a VA examination for this claim in February 2015, no medical opinion regarding the disability’s onset or nexus with these complaints in service was provided. As there is an indication the disability may be related to service, a remand is necessary to obtain a VA examination and medical opinion. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (VA is obliged to provide an examination where there is insufficient information to decide the claim and there is an indication the current disability may be associated with service). The Board notes that, while the Veteran’s Army National Guard records are associated with the claims file, the service treatment records from his deployments, coinciding with his second and third period of active duty service, are not. Further, the Veteran’s representative indicated at the Board hearing that there were outstanding private treatment records. On remand, the RO should attempt to obtain these pertinent records. The matters are REMANDED for the following action: 1. Attempt to obtain any service treatment records that are not already of record for the periods from October 2004 to November 2005 and August 2010 to September 2011 from the appropriate repositories, and associate those documents with the claims file. All such attempts should be documented in the claims file. If the records are unavailable, the Veteran’s file must be documented clearly to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Ask the Veteran to identify any private treatment that he may have had for hypertension and/or GERD that is not already of record. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records on his own behalf. 3. Then, schedule the Veteran for an examination with an appropriate clinician to determine the current severity of the Veteran’s service-connected hypertension. 4. Schedule the Veteran for an examination with an appropriate clinician to determine whether the diagnosis of GERD is related to the Veteran’s military service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. Following review of the claims file and examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. The examiner should solicit and address the Veteran’s lay statements regarding continuity of symptomatology since onset and/or since discharge from service. The examiner should address any other pertinent evidence of record, including whether the symptoms reported having begun during service are related to the current diagnosis of GERD, and whether the August 1991 gastritis diagnosis and subsequent hernia repair are related to the current diagnosis of GERD. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Josey, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.