Citation Nr: 21003200 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 19-18 948 DATE: January 19, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD), also claimed as acid reflux, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a respiratory disorder, claimed as bronchitis, to include as secondary to GERD, is remanded. REASONS FOR REMAND The Veteran had active duty service from December 1965 to December 1967, with service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Board remanded the appeal for additional development and it now returns for further appellate consideration. Pursuant to the September 2019 remand, the Veteran was afforded a VA examination in December 2019. At such time, the examiner noted a diagnosis of GERD and chronic obstructive pulmonary disease (COPD). She opined that it was less likely than not that such disorders were incurred during service. However, the examiner provided an inadequate rationale as she noted there were no records indicating a diagnosis or treatment for GERD or a respiratory condition during service. She also noted that GERD gave the symptom of heartburn, not stomach pain or diarrhea, and that the Veteran did not develop symptoms of chronic bronchitis until decades after service and that such disorder was typically from smoking. Nonetheless, in July 2020, the examiner provided an addendum opinion; however, she provided the same rationale regarding the Veteran’s GERD and added that stomach pain and diarrhea were not initial manifestations of the later diagnosed GERD, without explaining why. She also noted that the Veteran did not detail any symptoms or continuity of symptomatology about GERD in a June 2006 lay statement. With regard to the Veteran’s respiratory disorder, the examiner opined that it was less likely than not that the Veteran’s COPD or chronic bronchitis was related to herbicidal exposure during service in Vietnam as there was no medical evidence to support that herbicidal exposure caused COPD. She also noted that the Veteran stated that he had symptoms of chronic bronchitis for 20 years in the June 2006 statement, which would mean his symptoms began in 1986, and that there was no other records describing treatment or symptoms of a respiratory condition during service or until 2000. However, the sole basis for rejecting the Veteran’s claims cannot be the fact that there are no corroborating records. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an “absolute bar” to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) (“Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms”). Thus, the Board finds that a remand is necessary to obtain another addendum opinion that addresses such concerns. Moreover, the Veteran’s representative argued that GERD was a common condition connected to PTSD and that chronic bronchitis could be caused by GERD. Thus, on remand, an opinion should also be obtained to determine if the Veteran’s currently diagnosed GERD is secondary to his service-connected PTSD and whether his currently diagnosed COPD is secondary to his GERD.   The matters are REMANDED for the following action: Return the record, to include a copy of this Remand, to the July 2020 VA examiner who offered an opinion addressing the etiology of the Veteran’s GERD and respiratory disorder. If the VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. After a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s currently diagnosed GERD had its onset in or is otherwise related to the Veteran’s military service, to include his in-service complaints of stomach pains and diarrhea. Why or why not? (B) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s currently diagnosed GERD is (1) caused by or (2) aggravated (i.e., worsened) by his service-connected PTSD. For any aggravation found, please state, to the best of your ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. (C) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s respiratory disorder, currently diagnosed as COPD, had its onset in or is otherwise related to the Veteran’s military service, to include his acknowledged in-service exposure to herbicide agents. Why or why not? (D) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s currently diagnosed COPD is (1) caused by or (2) aggravated by his GERD. For any aggravation found, please state, to the best of your ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In offering such opinions, the examiner is advised that the absence of evidence of complaints, treatment, or a diagnosis referable to GERD and/or a respiratory disorder in the Veteran’s service treatment records cannot serve as the sole basis for a negative opinion. The examiner is also advised that a lack of post-service treatment records demonstrating a continuity of care cannot form the sole basis of a negative opinion. Thus, if the examiner rejects the Veteran’s lay statements as to onset and/or a continuity of symptomatology, he or she should provide a reason for doing so beyond the mere lack of corroborating records. The examiner is also advised that his/her rationale cannot be based solely on the fact that VA has not included COPD on the list of diseases acknowledged to be presumptively related to herbicide agents. In other words, the Board needs an opinion as to the likelihood that the Veteran’s respiratory disorder is related to his in-service exposure to herbicide agents despite the fact such is not included on the presumptive list. Further, if the examiner relies upon studies, articles, and/or medical literature in offering the opinion, he or she should discuss the significance of such in light of the Veteran’s specific case. A rationale for any opinion offered should be provided. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.