Citation Nr: 20004895 Decision Date: 01/22/20 Archive Date: 01/21/20 DOCKET NO. 09-06 166 DATE: January 22, 2020 REMANDED The issue of entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded for additional development. REASONS FOR REMAND The Veteran served on active duty from February 1970 to December 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from October 2008 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2012 and May 2015, the Board remanded the issue on appeal for additional development and, in June 2017, denied the claim. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In June 2018, the Court granted a Joint Motion for Partial Remand (JMPR) that vacated, in part, the June 2017 Board decision. In January 2019, the Board remanded the issue on appeal for additional development. Entitlement to service connection for GERD, to include as secondary to service-connected PTSD is remanded. By way of history, the Veteran contends that his GERD is directly related to his military service or, in the alternative, is secondary to his service-connected PTSD. In the June 2018 JMPR, the parties found that the Board erred in the June 2017 decision by failing to consider an April 1970 service treatment record that reflected that the Veteran had vomited. The parties noted that such error was significant in light of the fact that an October 2015 VA examiner noted that regurgitation was a sign or symptom that the Veteran had due to his esophageal condition, to include GERD. In this regard, the Board notes that prior opinions obtained in September 2014 and October 2015 found that the Veteran’s GERD was not related to his military service. Specifically, in September 2014, the examiner found that the Veteran had no documented history of complaints related to, diagnoses of, or treatment for GERD during his military service, and there was no clear history reported of symptoms, diagnoses, or treatments between his military service and his documented treatment in 2005. Therefore, the examiner concluded that the Veteran’s GERD was less likely than not incurred in or caused by his military service; rather, such disorder was due to his history of smoking, alcohol use, and being overweight. In October 2015, the examiner stated that the Veteran’s GERD was less likely than not incurred in or caused by any incident of active service. In support of such opinion, he noted that there was no evidence of frequent indigestion or stomach trouble in his service treatment records, to include his entrance and separation examinations. Rather, he stated that the Veteran’s GERD was more likely due to his history of smoking or history of alcohol use. Consequently, as neither VA examiner considered the Veteran’s report of vomiting in April 1970 during his military service, the Board found that a remand is necessary in order to obtain an addendum opinion addressing such report. An addendum opinion was obtained in September 2019. The clinician opined that the Veteran’s GERD was less likely than not related to service, including the April 1970 in-service complaint of vomiting. The clinician reasoned that the Veteran had no GERD-related symptoms prior to or following the April 1970 evaluation. The clinician determined that it was an isolated episode as there were no further treatments or findings of GERD. He concluded that the vomiting episode was acute and transitory with no residuals found on the November 1971 discharge examination. He also explained that it is presumed that any significant GERD condition which occurred during military service would be linked to and documented by associated medical documentation in service treatment records, which it was not. The Board points out that the examiner's rationale violated the rule espoused in Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007) that a “medical examiner cannot rely on the absence of medical records corroborating that injury to conclude that there is no relationship between the appellant's current disability and his military service.” Furthermore, in December 2019, the Veteran’s representative submitted a statement in rebuttal of the previous examiners’ opinions regarding secondary service connection. The representative referenced the following medical literature: Health-related quality of life in gastroesophageal reflux patients with noncardiac chest pain: Emphasis on the role of psychological distress, World Journal of Gastroenterology Association Between Anxiety and Depression and Gastroesophageal Reflux Disease: Results from a Large Cross-sectional Study, Journal of Neurogastroenterology and Motility Posttraumatic Stress Disorder and Gastrointestinal Disorders in the Danish Population, Epidemiology Based on the foregoing deficiencies, the Board finds that the VA clinician’s opinion is inadequate, and another opinion is necessary prior to adjudication of the claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). The matters are REMANDED for the following action: 1. Obtain a supplemental VA opinion from a gastroenterologist pertaining to the etiology of the Veteran’s GERD. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated gastroenterologist. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the opinion. The gastroenterologist should opine on the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s GERD had its onset during, or is otherwise related to, his active service? Please note that a medical opinion which concludes that a disease is not related to service solely because there is absence of medical records is inadequate. (b.) Is it at least as likely as not that the Veteran's GERD was proximately caused or aggravated by his service-connected PTSD? The gastroenterologist should note that this question requires two separate opinions: one for causation and a second for aggravation. The term “aggravation” means a worsening of the disability beyond its natural progression. If aggravation is found then, to the extent possible, the physician should attempt to establish a baseline level of severity of the GERD prior to aggravation by PTSD. The gastroenterologist is asked to identify the impact in this case, if any, of the line of research presented by the Veteran’s representative indicating that PTSD or psychiatric disorders are a factor in or could lead to GERD. (c.) In providing the requested opinions, the gastroenterologist should discuss the facts and the medical principles involved and the medical literature submitted by the Veteran and his representative. The opinions provided should cite to relevant medical literature (as discussed above), including literature not provided by the Veteran, if appropriate. A rationale for all opinions rendered should be provided. If a response to any of the aforementioned inquires cannot be provided without resort to speculation, the gastroenterologist should state as much, and further explain why it is not feasible to provide a medical opinion, to include whether additional information is needed. 2. After completing the requested actions, and any additional action deemed warranted, the AOJ should readjudicate the claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Bilstein 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.