Citation Nr: 20041767 Decision Date: 06/18/20 Archive Date: 06/18/20 DOCKET NO. 15-13 456 DATE: June 18, 2020 REMANDED Entitlement to a disability rating in excess of 30 percent for gastroesophageal reflux disease (GERD) with a hiatal hernia is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1991 to June 1995 and from August 2004 to February 2006. In February 2018, the Veteran and his wife provided testimony in a Travel Board hearing before the undersigned Veterans Law Judge at the Regional Office (RO) in Jackson, Mississippi. A copy of the hearing transcript is associated with the claims file. In August 2018, in pertinent part, the Board issued a decision that denied the Veteran’s claim of entitlement to a disability rating in excess of 30 percent for GERD with a hiatal hernia. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In December 2019, the Veteran and the Secretary of VA (parties) filed a Joint Motion for Partial Remand (JMPR) with respect to the part of August 2018 Board decision which denied the entitlement to a disability rating in excess of 30 percent for GERD with a hiatal hernia to vacate and remand the claim back to the Board, which was granted by the Court. Entitlement to a disability rating in excess of 30 percent for GERD with a hiatal hernia is remanded. The parties to the December 2019 JMPR found that the Board erred when it provided an inadequate statement of reasons or bases for denying the claim. Specifically, the Board failed to apply 38 C.F.R. § 4.7 by finding that the Veteran’s GERD symptoms do not meet the criteria for a 60 percent rating but failed to address whether the disability picture more nearly approximates the criteria for a 60 percent rating. The parties agree that remand is warranted to address whether the Veteran’s disability picture more nearly approximates the criteria for a 60 percent rating for GERD. The Board finds that remand is warranted to fully assist the Veteran with the development of his claim. After a review of the claims file, the Board finds that there are outstanding medical records that are relevant to the issue on appeal. During the February 2018 Travel Board hearing, the Veteran testified that he was constantly back and forth to the doctor with his digestive system symptoms. He stated that his outside doctor treated him for anemia and other medication for blood, however, he was still losing blood through the internal hemorrhoid and had regular hemorrhoids which he was given depository [sic] for. The Veteran reported that he was given a solution to coat his stomach and in the year prior to the hearing. He also testified that was told by his doctor that the medication he took caused his bowels to harden, which also caused constipation. He reported that his acid reflux would wake him up at night. He stated that the VA doctors found that he did not have anemia, but his outside doctor found that his numbers were out of range, which would indicate anemia. In April 2015 correspondence, the Veteran also reported that his medication was increased from 20 mg of omeprazole to 40 mg in May 2012 and that he was treated for Helicobacter pylori. He also stated that he has been anemic since June 2007 when he was diagnosed by Dr. Jola Roszkowsa. The record includes sporadic private medical records from Dr. Robert Tatum piecemeal, including a February 2015 record which shows that the Veteran is still anemic and there are indications that relevant records are outstanding. The record also includes VA medical records up to August 2015, with some records associated piecemeal up to August 2016. However, as treatment for the Veteran’s GERD has been ongoing, updated VA records should be obtained and the Veteran should be provided an opportunity to identify any outstanding relevant private medical records on remand. Finally, the Veteran was last afforded a VA examination in April 2009 in order to establish the severity of his GERD with a hiatal hernia disability related symptoms. The Board finds that in light of the Veteran’s statements and medical evidence which is suggestive of a worsening of the disability, a remand is necessary to afford the Veteran an opportunity to undergo a VA examination to assess the current nature, extent and severity of his GERD with a hiatal hernia disability. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private medical records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, related to treatment of his service-connected GERD with a hiatal hernia disability, to include but are not limited to records from the following medical professionals: • Dr. Robert Tatum at the Tatum Medical Clinic in Canton, Mississippi; • Dr. Jola Roszkowsa; and • any other private medical professional whose records would be relevant to the issue on appeal. Any negative response should be in writing and associated with the claims file. 2. Obtain all outstanding VA treatment records, particularly since August 2015, and associate them with the claims file. 3. Schedule the Veteran for a VA examination to evaluate the current severity of his service-connected GERD with a hiatal hernia disability. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Cheng, 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.