Citation Nr: 21061928 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 18-27 849 DATE: October 5, 2021 ORDER The application to reopen a claim of service connection for skin disability is granted. The application to reopen a claim of service connection for gastroesophageal reflux disease (GERD) is granted. The application to reopen a claim of service connection for Bell's palsy is granted. Entitlement to service connection for pseudofolliculitis barbae is granted. Entitlement to service connection for residuals of Bell's palsy is granted. Entitlement to an increased (compensable) rating for bilateral hearing loss is denied. REMANDED Entitlement to service connection for GERD is remanded. FINDINGS OF FACT 1. The Veteran's claim of service connection for skin disability was originally denied in a January 2011 rating decision on the basis that there was no evidence of any such disability that was related to service; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 2. The Veteran's claim of service connection for GERD (characterized as acid reflux) was originally denied in the January 2011 rating decision on the basis that there was no evidence of any such disability that was related to service; the Veteran submitted a timely notice of disagreement (NOD) with the denial of service connection for acid reflux in January 2012 and a statement of the case (SOC) was issued in September 2012, but the Veteran did not file a substantive appeal. 3. The Veteran's claim of service connection for Bell's palsy was originally denied in a July 2012 rating decision on the basis that there was no evidence of any such disability that was related to service; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 4. Evidence received since the January 2011 and July 2012 agency of original jurisdiction (AOJ) decisions includes information that was not previously considered and which relates to unestablished facts necessary to substantiate the claims of service connection for skin disability, GERD, and Bell's palsy, the absence of which was the basis of the previous denials. 5. The Veteran's pseudofolliculitis barbae began during active service. 6. The Veteran's Bell's palsy manifested to a compensable degree within one year of his separation from service. 7. The Veteran has at worst level I hearing in both ears. CONCLUSIONS OF LAW 1. The AOJ's January 2011 and July 2012 rating decisions which denied the claims of service connection for skin disability, GERD, and Bell's palsy are final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.20, 19.32, 19.52, 20.1103. 2. The evidence received since the January 2011 and July 2012 AOJ decisions is new and material and reopening of the claims of service connection for skin disability, GERD, and Bell's palsy is therefore warranted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. The criteria for service connection for pseudofolliculitis barbae are met. 38 U.S.C. §§ 1110, 1154(b), 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for residuals of Bell's palsy are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for an increased (compensable) rating for bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.85, 4.86, Diagnostic Code (DC) 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1999 to September 2003, which includes service in the Southwest Asia theater of operations. These matters come before the Board of Veterans' Appeals (Board) from a July 2017 rating decision. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a December 2020 hearing. The Board subsequently sent the Veteran a letter in March 2021 which informed him that the Board was unable to produce a written transcript of the December 2020 hearing and asked him to indicate whether he wanted to attend a new hearing. The Veteran responded later in March 2021 that he did not wish to have another Board hearing and that he wanted his case to be considered based on the evidence of record. Therefore, the Board may proceed to adjudicate the matters on appeal. As for characterization of the issues on appeal, claims of service connection for skin disability, GERD (characterized as acid reflux), and Bell's palsy were denied by way of final January 2011 and July 2012 rating decisions. Where the claim in question has been finally adjudicated, the Board must initially determine whether new and material evidence has been submitted with regard to the claims of service connection for skin disability, GERD, and Bell's palsy. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Only where the Board concludes that new and material evidence has been received does it have jurisdiction to consider the merits of these claims. Hickson v. West, 11 Vet. App. 374, 377 (1998). Therefore, the Board has included the issues of whether new and material evidence has been received to reopen the claims of service connection for skin disability, GERD, and Bell's palsy. I. Applications to Reopen Generally, an AOJ decision denying a claim which has become final may not thereafter be readjudicated or allowed. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The newly presented evidence is presumed to be credible for purposes of determining whether it is new and material. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purpose of determining whether new and material evidence has been presented to reopen a claim, the evidence for consideration is that which has been presented or secured since the last time the claim was finally disallowed on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The applications to reopen claims of service connection for skin disability, GERD, and Bell's palsy The AOJ initially denied the Veteran's claims of service connection for skin disability and GERD (characterized as acid reflux) in a January 2011 rating decision on the basis that there was no evidence of any such disabilities that were related to service. The Veteran was notified of the January 2011 decision, he did not appeal the denial of service connection for skin disability within one year of the issuance of the January 2011 decision, and new and material evidence was not received within that year. Therefore, the January 2011 decision became final as to the denial of service connection for skin disability. See 38 U.S.C. § 7105 (d)(3); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.52(a), 20.1103. With respect to the January 2011 denial of service connection for acid reflux, the Veteran submitted a timely NOD with this decision in January 2012 and an SOC was issued in September 2012. Appellate review is initiated by an NOD and completed by a substantive appeal filed after an SOC has been furnished to an appellant. 38 U.S.C. § 7105 (a); 38 C.F.R. § 19.20. A substantive appeal must be filed within 60 days from the date of mailing of an SOC, or within the remainder of the one-year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 U.S.C. § 7105 (b)(2); 38 C.F.R. § 19.52 (b)(1). In the absence of a properly perfected appeal, the AOJ may close the appeal and the decision becomes final. 38 U.S.C. § 7105 (d)(3); Roy v. Brown, 5 Vet. App. 554, 556 (1993); 38 C.F.R. § 19.32. The AOJ did so in this case, as evidenced by the fact that it did not certify to the Board the issue of entitlement to service connection for acid reflux following the September 2012 SOC. As neither the Veteran nor his representative submitted any document that could be construed as a timely substantive appeal pertaining to the claim of service connection for acid reflux following the September 2012 SOC, the AOJ closed the appeal. The AOJ did not certify this issue to the Board at that time and no further action was taken by VA to suggest that the issue was on appeal. Thus, the January 2011 rating decision also became final as to the denial of service connection for acid reflux. See 38 U.S.C. § 7105 (d)(3); Fenderson v. West, 12 Vet. App. 119, 128-31 (1999) (discussing the necessity of filing a substantive appeal which comports with governing regulations); 38 C.F.R. §§ 3.104, 20.1103. The AOJ initially denied the Veteran's claim of service connection for Bell's palsy in a July 2012 rating decision on the basis that there was no evidence of any such disability that was related to service. The Veteran was notified of the July 2012 decision, he did not appeal the decision within one year of its issuance, and new and material evidence was not received within that year. Therefore, the July 2012 decision became final as to the denial of service connection for Bell's palsy. See 38 U.S.C. § 7105 (d)(3); Bond, 659 F.3d at 1362; 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.52(a), 20.1103. The pertinent new evidence received since the January 2011 and July 2012 denials of service connection for skin disability, GERD, and Bell's palsy includes a July 2017 VA skin examination report and the report of a July 2017 VA Gulf War examination. This evidence includes diagnoses of pseudofolliculitis barbae, GERD, and incomplete recovery of Bell's palsy, a report of residual symptoms of Bell's palsy (including facial weakness and eye watering), and a medical opinion that the Veteran's claimed skin disability was incurred in service. Therefore, the additional evidence pertains to elements of the claims of service connection for skin disability, GERD, and Bell's palsy that were previously found to be lacking and raises a reasonable possibility of substantiating the claims by indicating that the Veteran has current skin disability, GERD, and residuals of Bell's palsy. The evidence is, therefore, new and material, and the claims of service connection for skin disability, GERD, and Bell's palsy are reopened. II. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Organic diseases of the nervous system (e.g., Bell's palsy) are included among the list of chronic diseases. Although service connection on any of the presumptive bases noted above may not be established, a veteran is not precluded from establishing service connection on a direct basis. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). 1. Entitlement to service connection for pseudofolliculitis barbae The Veteran contends that he has current skin disability which had its onset in service. The Board finds, for the following reasons, that the Veteran has a current diagnosis of pseudofolliculitis barbae and that this disability began during service. A July 2017 VA skin examination report shows that the Veteran has been diagnosed as having pseudofolliculitis barbae. Therefore, current skin disability has been demonstrated. Additionally, there is evidence of skin problems in service and evidence of continuous skin symptoms in the years since service. In this regard, the Veteran reported during the July 2017 VA skin examination that he developed "razor bumps and pustules" on his face during service from frequent shaving, that he was given topical medication, and that he was placed on a shaving profile. The Veteran's DD Form 214, an October 2017 VA mental health initial evaluation consultation note, and the report of a December 2019 VA psychiatric examination reflect that he served in Southwest Asia from March 2003 to June 2003 and that he reported exposure to incoming enemy fire while performing guard duty in Southwest Asia. A determination that a veteran engaged in combat with the enemy may be supported by any evidence which is probative of that fact, and there is no specific limitation of the type or form of evidence that may be used to support such a finding. See VAOPGCPREC 12-99 (October 18, 1999) (combat determination should be made on a case by case basis where there is no medal specifically indicating combat service). Evidence submitted to support a claim that a veteran engaged in combat may include the veteran's own statements and an "almost unlimited" variety of other types of evidence. Gaines v. West, 11 Vet. App. 353, 359 (1998). Receiving enemy fire or firing on an enemy can constitute participation in combat. Sizemore v. Principi, 18 Vet. App. 264 (2004). The Veteran is competent to report his exposure to incoming enemy fire in service and there is no evidence that explicitly contradicts his reports. Therefore, the Board finds that his reports of combat exposure in service are credible and that there is sufficient evidence that the Veteran participated in combat/was exposed to incoming enemy fire while serving in Southwest Asia. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships of service. 38 U.S.C. § 1154 (b). The combat rules not only reduce the evidentiary burden for establishing in-service injury but allow a combat veteran to use "satisfactory lay or other evidence" to establish that he incurred the disability itself in service, even in cases where "there is no official record" that such injury or disability occurred. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012). The Veteran's reports of skin problems in service are satisfactory evidence and the reports are consistent with the circumstances of his service in Southwest Asia. There is no clear and convincing evidence to the contrary. Therefore, the presence of skin problems in service is established. Moreover, the Veteran's post-service medical records and lay statements indicate that he has experienced continuous skin symptoms in the years since service (see the July 2017 VA skin examination report). The Veteran is competent to report continuous skin problems in the years since service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Also, there is no evidence to explicitly contradict the Veteran's reports and they are generally consistent with the evidence of record. Thus, the Board finds that the reports of continuous skin symptoms in the years since service are credible. Moreover, the physician who conducted the July 2017 VA skin examination explained that the Veteran developed pustules to his face/bearded area after razor shaving and dry shaving on a frequent basis while on active duty, and that he continued to experience this skin condition on a chronic basis. His signs and symptoms were consistent with pseudofolliculitis barbae and he was diagnosed and treated for this condition during service. Therefore, it was likely ("at least as likely as not") that the pseudofolliculitis barbae (shaving skin condition) was incurred during active duty. The July 2017 opinion is based upon an examination of the Veteran, a review of his claims file, and consideration of his reported history, and it is accompanied by a specific rationale that is consistent with the evidence of record. Therefore, the July 2017 opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). In sum, the evidence reflects that the Veteran experienced skin problems in service and that there have been continuous skin symptoms in the years since service. He also experiences current pseudofolliculitis barbae, and there is a probative medical opinion that this disability had its onset in service. There is no medical opinion that is contrary to this conclusion. Thus, the preponderance of the evidence is in favor of a conclusion that the Veteran's pseudofolliculitis barbae had its onset in service and service connection for this disability is warranted. 2. Entitlement to service connection for residuals of Bell's palsy The Board finds, for the following reasons, that the Veteran experiences current residuals of Bell's palsy and that this disability manifested to a compensable degree within one year of his separation from service. The July 2017 VA Gulf War examination report indicates that the Veteran reported residual left-sided facial weakness (e.g., weak smile on the left side and an impaired ability to close the left eye at night) and left eye watering, and that he has been diagnosed as having incomplete recovery of Bell's palsy. Therefore, current residuals of Bell's palsy have been demonstrated. Moreover, VA treatment records dated in May 2004 reflect that the Veteran sought treatment for right-sided facial weakness. Examination revealed right upper and lower motor neuron palsy of the VII cranial nerve, deviation of the angle of the mouth, and an inability to shut the right eye tightly. The Veteran was diagnosed as having idiopathic Bell's palsy. In sum, the evidence reflects that the Veteran experiences current residuals of Bell's palsy and that this disability (an organic disease of the nervous system) manifested to a compensable degree within one year of the Veteran's September 2003 separation from service. Therefore, service connection for residuals of Bell's palsy is warranted. III. Increased Rating Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports considering the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Entitlement to an increased (compensable) rating for bilateral hearing loss Hearing loss is rated on the basis of examination results including a controlled speech discrimination test (Maryland CNC), and a pure tone audiometric test of pure tone decibel thresholds at 1000, 2000, 3000, and 4000 Hz with an average pure tone threshold obtained by dividing these thresholds by four. 38 C.F.R. § 4.85. Once these test results have been obtained, employing Table VI, a Roman numeral designation of hearing impairment is ascertained based on a combination of the percent of speech discrimination and pure tone threshold average. Once a Roman numeral designation of auditory acuity level for each ear has been determined, Table VII is used to determine the percentage evaluation for bilateral hearing loss by combining the Roman numeral designations of auditory acuity level for hearing impairment of each ear. Id. There is an alternative method of rating hearing loss in defined instances of exceptional hearing loss. In such exceptional cases, the Roman numeral designation for hearing loss of an ear may be based only on pure tone threshold average, using Table VIA, or from Table VI, whichever results in the higher Roman numeral. Exceptional hearing loss exists when the pure tone threshold at the frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more; or where the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. In the latter situation, the higher Roman numeral, determined from Table VI or VIA, will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. Considering the pertinent evidence in light of the applicable rating criteria and considerations, the Board finds, for the following reasons, that a compensable rating for bilateral hearing loss is not warranted. At the outset, the Board acknowledges that the Veteran was most recently afforded a VA examination to assess the severity of his service-connected hearing loss in May 2018. The May 2018 examination provided the findings necessary to properly rate the Veteran's disability based upon an in-person examination, he has not reported any changes in his hearing loss since that time, and the record does not otherwise suggest any changes. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (mere passage of time does not trigger need for a new VA examination, absent evidence of a change in the disability). Thus, a new VA examination for his hearing loss need not be conducted merely due to the passage of time since the last examination. The Veteran's claim for an increased rating for bilateral hearing loss was received on May 19, 2017. During a May 2018 VA audiological examination, the Veteran reported that as a result of his hearing loss, he experienced decreased hearing in both ears which made communication difficult. Examination revealed that his pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 10 35 45 26 LEFT 20 60 65 55 50 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. Using Table VI, the May 2018 VA examination revealed level I hearing in both ears. Combining level I hearing for both ears according to Table VII yields a rating of 0 percent. The Veteran has expressed his belief that the severity of his hearing loss warrants a higher rating. He is competent to report the symptoms of his hearing disability and the Board has no legitimate basis to challenge the credibility of his contentions. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. However, ratings for hearing loss are determined by a mechanical application of the VA rating schedule to the numeric designations assigned based on audiometric test results. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The lay statements of record do not show that the Veteran has met the specific pure tone thresholds and/or speech discrimination percentages required for a higher rating for bilateral hearing loss at any time during the claim period. In sum, the record neither shows that the evidence is so evenly balanced as to warrant a compensable rating for bilateral hearing loss at any time during the claim period, nor does the evidence show that the Veteran's hearing disability more closely approximates the criteria for a higher rating. Therefore, a compensable rating for bilateral hearing loss is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As a final matter, the Board finds that, in conjunction with the claim for an increased rating for bilateral hearing loss, no other related issues have been raised by the Veteran or his representative, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Entitlement to service connection for GERD is remanded. For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of "a qualifying chronic disability" that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026. 38 C.F.R. § 3.317 (a)(1). For purposes of 38 C.F.R. § 3.317, qualifying chronic disabilities include, among other things, a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317 (a)(2). A MUCMI is a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. MUCMIs include, but are not limited to, chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders 38 C.F.R. § 3.317. The Veteran was afforded a VA Gulf War examination in July 2017 and was diagnosed as having GERD. The nurse practitioner who conducted the examination opined that it was not likely that this disability was related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner reasoned that GERD is a distinct condition with clear and specific etiology and diagnosis. GERD has not been associated with the illnesses or exposures described in veterans returning from the Gulf War, as published in peer-reviewed medical literature. The July 2017 opinion is inadequate because it only addresses whether the Veteran's GERD is related to environmental exposures in Southwest Asia and does not otherwise address whether the disability had its onset in service or is otherwise related to service. Also, although the July 2017 examiner indicated that the Veteran's GERD has a clear and specific etiology, an illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive, and the determination of whether an illness is "medically unexplained" is particular to the claimant in each case. Stewart v. Wilkie, 30 Vet. App. 383, 389 (2018). In light of the above inadequacies of the July 2017 opinion, a remand is necessary to obtain a new opinion as to whether the Veteran's GERD is related to service. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Oklahoma Vista electronic records system and are dated to November 2018. Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. The matter is REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for GERD, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for GERD from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's outstanding VA treatment records from the Oklahoma Vista electronic records system for the period since November 2018; and all such relevant records from any other sufficiently identified VA facility. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician as to whether the Veteran's GERD is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any GERD experienced by the Veteran since approximately May 2017 (1) began during active service; OR (2) is related to an injury or disease during service? (b) Is it at least as likely as not that any GERD experienced by the Veteran since approximately May 2017 has at least a partially understood pathophysiology AND etiology? (c) Is the Veteran's acid reflux a symptom of an identifiable disability (including, but not limited to, GERD)? If not, does this symptom represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology (including, but not limited to, a functional gastrointestinal disorder)? The clinician must provide reasons for each opinion given. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.