Citation Nr: 20021301 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 15-24 716 DATE: March 25, 2020 REMANDED Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from November 1967 to November 1969. This case comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2015 Department of Veterans Affairs (VA) rating decision. A July 2018 Board decision, in pertinent part, denied a rating higher than 10 percent for GERD, which the Veteran appealed to the United States Court of Appeals for Veterans Claims (CAVC). In an August 2019 Order, the CAVC granted a July 2019 Joint Motion for Partial Remand of the parties, thereby vacating that part of the Board decision that denied a rating in excess of 10 percent for GERD and remanding the matter to the Board for action consistent with the terms of the Joint Motion. Entitlement to a rating in excess of 10 percent for GERD In the July 2019 Joint Motion, the parties agreed that the Board failed to address a January 2013 VA outpatient treatment record which referred to the Veteran’s complaints of sporadic episodes of chest pain, or to acknowledge the Veteran’s September 2015 assertions that he has reported to treatment providers such symptoms as arm and shoulder pain. It is also noted that on a May 2016 statement, the Veteran related that he went to the emergency department for “reflux attacks” with pain in the left side of his chest that went through his shoulder and arm. A review of the medical records shows that he has been seen in the emergency department. For example, in February 2016, he was seen for complaints of GERD-like symptoms and gas with tightness in his chest, but he arrived with tachycardia and so was worked up for a heart-related problem. The Veteran was last examined by the VA in July 2015, and in the view of the Board another examination to discern all current symptoms of his GERD, including whether any substernal, arm, and/or shoulder pain is attributable to it, is warranted. It is also noted that the July 2015 VA examiner has listed sleep disturbance as a sign/symptom of GERD, and it should be determined whether this continues and, if so, its frequency and severity. The matters are REMANDED for the following: 1. Secure the updated complete records (those not already associated with the record) of all VA evaluations and treatment the Veteran has received for GERD. 2. Then, arrange for an examination of the Veteran by a gastroenterologist to assess the severity of his GERD. (If a gastroenterologist is not available to examine the Veteran, he should be examined by an appropriate medical professional and his file provided to a gastroenterologist for an opinion.) The claims file should be made available for review by the examiner. Any indicated tests or studies should be completed. The examiner should describe findings in detail, specifically noting the presence or absence of the symptoms and impairment in the criteria for ratings above 10 percent (see 38 C.F.R. § 4.114, Diagnostic Code 7346). The examiner should specifically consider all subjective symptoms suggested by the record or reported by the Veteran, to specifically include dysphagia, regurgitation, chest pain, and shoulder and arm pain. The examiner should determine whether such symptoms are associated with the Veteran’s GERD and should evaluate the frequency/severity of each symptom associated with GERD, to include any sleep disturbances. If the examiner determines that any reported/documented symptoms are not associated with GERD, the etiology of such symptoms considered more likely should be identified, with citation to the record as appropriate. The examiner should indicate whether or not the symptoms associated with GERD are productive of “considerable impairment of health.” The examiner must explain the rationale for all opinions, citing to supporting clinical data. George R. Senyk Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Debbie Breitbeil, 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.