Citation Nr: 21004927 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 14-07 125A DATE: January 28, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) and hiatal hernia, also claimed as trouble swallowing and acid reflux, is remanded. REASONS FOR REMAND The Veteran served on active duty for training (ACDUTRA) from March to August 2000 and on active duty (AD) from May 2002 to April 2006. In January 2018 and May 2019, the Board remanded this claim to obtain the Veteran’s private treatment records and for an examination and medical opinion. In February 2018 and November 2019, the agency of original jurisdiction (AOJ) mailed the Veteran VA Forms 21-4142 and 21-4142a to obtain his authorization to release his confidential medical treatment records to VA. To date, however, he has not submitted those forms. Additionally, as also directed, the Veteran underwent a VA examination, but the examination is inadequate to address his most recent contention that his GERD and hiatal hernia are caused or aggravated by his service-connected PTSD and migraines. Accordingly, still more medical comment is needed before deciding the appeal of this claim.   Entitlement to service connection for GERD and hiatal hernia, also claimed as trouble swallowing and acid reflux, again is remanded. The Veteran initially contended that his GERD and hiatal hernia began during his service or were directly caused by his service during the Persian Gulf War. To adequately address those contentions, the Board remanded this claim for an examination and medical opinion. In January 2020, a VA examiner opined that the claimed condition was less likely than not incurred in service. The VA examiner referenced the Veteran’s service treatment records (STRs) and post-service treatment records. The VA examiner reasoned that there are no records showing the Veteran complained of, received treatment for, or was diagnosed with GERD, hiatal hernia, or difficulty swallowing while in service or immediately after his service. Since that January 2020 VA examination and opinion, however, the Veteran’s representative has submitted a Brief in January 2021 additionally contending that the Veteran’s GERD and hiatal hernia are secondary to (meaning caused or aggravated by) his service-connected PTSD and migraines. The representative referenced medical journals positing a connection between GERD and PTSD and hiatal hernia and migraines, but not sufficiently to determine whether there is the required causation or aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). And when, as here, VA has had the Veteran examined for a needed medical opinion, it must ensure the examination and opinion are adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, supplemental comment is needed to address this additional theory of entitlement. 38 C.F.R. § 4.2.   Accordingly, this claim is again REMANDED for the following still additional development and consideration: Obtain still more medical comment (addendum opinion) concerning the origins of the Veteran's GERD and hiatal hernia – including in terms of whether these conditions are at least as likely as not caused OR aggravated by his service-connected disabilities, so by his PTSD, migraines, irritable bowel syndrome (IBS), sleep apnea, and traumatic brain injury (TBI). For this purpose, aggravation means any incremental increase in the GERD and/or hiatal hernia owing to a service-connected disability or disabilities. *The January 2020 medical opinion already obtained as a result of prior remands of this claim addressed the notion of direct service connection (meaning the premise the GERD and hiatal hernia are directly related to the Veteran’s service), concluding they are not. But additional medical comment is needed concerning the additionally posited notion, instead, of secondary service connection. Rationale for the opinion is essential. The absence of evidence of treatment for GERD and/or hiatal hernia in the Veteran's STRs or even post-service treatment records sooner than indicated cannot be the sole reason for providing an unfavorable opinion, certainly not in the context of secondary service connection. However, it is permissible to consider this as one of several factors,   provided there also is explanation of why it is reasonable to expect documentation of specific complaints, etc., in the treatment records sooner than when indicated. *The VA examiner also is asked to address the medical journals positing a connection between GERD and PTSD and hiatal hernia and migraines that the Veteran’s representative cited in his recent January 2021 Brief. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Hamm, 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.