Citation Nr: 20060596 Decision Date: 09/15/20 Archive Date: 09/15/20 DOCKET NO. 15-08 075 DATE: September 15, 2020 REMANDED Entitlement to service connection for calcifications of the brain is remanded. Entitlement to service connection for large duodenum ulcer/peptic ulcer, to include as due to service-connected disabilities, is remanded. Entitlement to service connection for a swallowing disability, to include as due to service-connected disabilities, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1969 to December 1970. The Veteran had a videoconference hearing before the undersigned in August 2018. A transcript of the hearing has been associated with the claims file. This appeal was previously before the Board in March 2019, at which time it was remanded for further development. Unfortunately, remand is again required. 1. Entitlement to service connection for calcifications of the brain is remanded. In its March 2019 decision, the Board directed the agency of original jurisdiction (AOJ) to schedule the Veteran for an examination to assess the nature and etiology of his claimed brain disability. Specifically, the examiner was asked to clarify the Veteran’s current brain disabilities and offer an opinion as to whether any current brain disability clearly and unmistakably had onset prior to service and/or whether any current brain disability was clearly and unmistakably not aggravated by service. Further, if warranted, the examiner was to provide an opinion regarding direct service connection. While the Veteran underwent VA examination in November 2019, the Board finds that a new opinion is required as the November 2019 examiner did not adequately answer the questions asked by the Board. Specifically, when providing the opinions requested, the examiner appeared to misconstrue the clear and unmistakable standard and, in doing so, created confusion and ambiguity in his opinion. Indeed, the examiner initially stated that the Veteran’s subarachnoid hemorrhage occurred prior to service and that he did not have any additional subarachnoid hemorrhage in service. However, the examiner later stated that the Veteran entered service without any disability. Further, when providing an opinion regarding aggravation, the examiner appeared to focus on whether it was clear that any hemorrhage was aggravated during service, utilizing the wrong standard. Therefore, the claim should be remanded for a new examination and opinion. 2. Entitlement to service connection for large duodenum ulcer/peptic ulcer, to include as due to herbicide agent exposure, is remanded. 3. Entitlement to service connection for a swallowing disability, to include as due to herbicide agent exposure, is remanded. 4. Entitlement to service connection for GERD, to include as due to herbicide agent exposure, is remanded. In its March 2019 decision, the Board directed the AOJ to schedule the Veteran for an examination to assess the nature and etiology of his claimed ulcer, swallowing, and GERD disabilities. The examiner was directed to provide opinions regarding both direct and secondary service connection. The Veteran underwent VA examination in October 2019. While the examiner provided opinions regarding direct service connection, an opinion regarding secondary-service connection was not proffered, to specifically include whether the Veteran’s GERD is caused or aggravated by the Veteran’s service-connected PTSD. Therefore, remand is warranted so that opinions regarding causation and aggravation may be obtained. The matters are REMANDED for the following action: 1. Obtain a medical opinion from a clinician other than the October 2019 VA examiner addressing the etiology of the Veteran’s brain calcification disability. A copy of the claims file should be sent to, and reviewed by the reviewing clinician. Upon review of the file, the reviewing clinician should respond to each of the following: (a.) Is it clear and unmistakable (i.e. undebatable) that any current brain calcifications/aneurisms disability had onset prior to the Veteran’s entry into active duty service? (b.) For any disability where the answer to (b) is “yes,” then is it also clear and unmistakable (i.e. undebatable) that such disability was NOT aggravated beyond its natural progression during the Veteran’s period of active duty service? The examiner should consider the Veteran’s contention that he recalled having headaches in service, and that use of the 155mm Howitzer aggravated his brain hemorrhage beyond its natural progression. (c.) For any disability where the answer to either (b) or (c) is “no,” assume as true that the Veteran entered service without that disability. With that assumption in mind, is it at least as likely as not (50 percent or greater probability) that such disability had onset in, or is otherwise related to the Veteran’s period of service, to include firing 155mm Howitzers, his presumed exposure to herbicides and/or contaminated rice paddy water in South Vietnam? All opinions should be supported by a medical explanation or rationale. If in the opinion of the reviewing clinician answers the questions above cannot be provided without an in-person or virtual interview or examination, such should be scheduled. 2. Obtain medical opinions from a clinician other than the October 2019 VA examiner addressing the etiology of the Veteran’s ulcer, swallowing, and GERD disabilities. A copy of the claims file should be sent to, and reviewed by the reviewing clinician. Upon review of the file, the reviewing clinician or clinicians should respond to each of the following: (a.) Is at least as likely as not (50 percent or greater probability) that the Veteran has a swallowing disability that is caused or aggravated beyond its natural progression by his claimed brain calcification disability, GERD, or ulcers? If the Veteran’s swallowing condition is not actually a stand-alone disability, but rather is a symptom or manifestation of another disability, this should be made clear. (b.) Is it at least as likely as not that the Veteran’s GERD and/or ulcer disability is caused or aggravated beyond its natural progression by his service-connected posttraumatic stress disorder (PTSD)? All opinions should be supported by a medical explanation or rationale. If in the opinion of the reviewing clinician answers the questions above cannot be provided without an in-person or virtual interview or examination, such should be scheduled. 3. Readjudicate the appeal. If the benefits sought remain denied, issue the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Bristow Williams, 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.