Citation Nr: 21063551 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 11-00 326 DATE: October 14, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a gastrointestinal disorder including gastroesophageal reflux disease (GERD), and other than an ulcer disorder, including as due to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1968 to March 1970. These matters are before the Board of Veterans' Appeals (Board) on appeal from March 2009 and October 2009 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2016, the Veteran testified, sitting in Waco, Texas, before the undersigned via a videoconference hearing. A transcript of the hearing has been associated with the virtual file and reviewed. These issues were most recently before the Board in March 2021, at which time they were remanded for further development, as discussed below. The Board finds that the remand directives were not substantially complied with and thus another remand is warranted. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for a back disorder is remanded. A March 2021 Board decision remanded the claim in accordance with the October 2020 CAVC-approved Joint Motion for Partial Remand (JMPR), which found that the Board did not ensure substantial compliance with prior remand orders and did not provide an adequate statement in support of its denial of the aforementioned claim. The Board directed the Agency of Original Jurisdiction (AOJ) to obtain a VA medical opinion that adequately discusses the Veteran's post-service reports of symptoms for a back disorder. 03/01/2021, BVA Decision. A July 2021 VA examination noted the diagnosis of lumbosacral strain and bilateral lumbar radiculopathy. The examiner opined that the Veteran's back condition is less likely than not related to his period of active service. The rationale was based on a lack of documented medical treatment showing a continuity of the same symptomatology since service. 07/08/2021, C&P Exam. And, in a separate August 2021 medical opinion, the same VA examiner again opined that the Veteran's back condition is less likely than not related to his period of active service. The examiner merely indicated that the claims file was reviewed and made note of the Veteran's complaints of back pain since separation from service. However, the examiner did not provide a rationale in support of the opinion. 08/17/2021, C&P Exam. The Board finds the July 2021 VA examination and August 2021 VA medical opinion to be incomplete. Although the examiner made note of the lack of treatment records concerning the Veteran's back condition, the examiner did not provide a sufficient rationale in support of the opinions. Moreover, the examiner did not provide an opinion as to the etiology of the back condition. As such, the Board finds that the remand directives were not substantially complied with and, therefore, another remand is warranted. Stegall, 11 Vet. App. at 271. 2. Entitlement to service connection for a gastrointestinal disorder including GERD, and other than an ulcer disorder, including as due to service-connected PTSD, is remanded. A March 2021 Board decision remanded the claim in accordance with the October 2020 CAVC-approved JMPR, which found that the Board did not ensure substantial compliance with prior remand orders and did not provide an adequate statement in support of its denial of the aforementioned claim. The Board directed the AOJ to obtain a VA medical opinion to determine whether Veteran's service-connected PTSD led to alcohol use that has aggravated his gastrointestinal disorder. The examiner was also directed to provide an opinion as to whether any gastrointestinal disorder had its onset in or is otherwise related to the Veteran's period of active service. 03/01/2021, BVA Decision. A July 2021 VA examination noted the diagnosis of GERD. The examiner opined that the Veteran's GERD is less likely than not related to his period of active service. The rationale was based on a lack of documented medical treatment regarding GERD during active service. The examiner also opined that the Veteran's GERD is less likely than not related to his service-connected PTSD but did not provide a rationale in support of the opinion. 07/08/2021, C&P Exam. And, in a separate August 2021 medical opinion, the same VA examiner again opined that the Veteran's GERD is less likely than not aggravated by or proximately due to any service-connected disability. The examiner asserted that there is no documentation or literature that supports that the Veteran's PTSD led to alcohol use that caused or aggravated his gastrointestinal disorder. However, the examiner did not provide any summary or citation to medical literature that was reviewed. Moreover, the examiner did not indicate whether medical literature exists that indicates that PTSD could cause alcohol abuse, as well as any separate medical literature that indicates whether alcohol abuse aggravates or causes GERD. 08/17/2021, C&P Exam. The Board finds the July 2021 VA examination and August 2021 VA medical opinion to be incomplete. Although the examiner made note of the lack of medical literature that comprehensively addresses the link between PSTD, alcohol abuse, and GERD, the examiner did not discuss whether medical literature exists supporting the contention that PTSD caused alcohol abuse, as well as whether literature exists indicating whether alcohol abuse aggravates or causes GERD. Moreover, the examiner otherwise did not provide a rationale regarding whether GERD is directly related to the Veteran's period of active service that did not entirely rely on the lack of treatment records. As such, the Board finds that the remand directives were not substantially complied with and, therefore, another remand is warranted. Stegall, 11 Vet. App. at 271. These matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. Additionally, request the Veteran to submit any relevant private treatment reports or provide VA with authorization to obtain any such records. 2. After completing directive # 1, obtain an addendum opinion from an appropriate clinician regarding nature and etiology of any diagnosis of a back disorder. An in-person examination is not required unless deemed necessary by the clinician. The clinician should review the virtual file, including a copy of this Remand: The clinician is to address: (a.) Whether it is at least likely as not (probability of at least 50 percent or more) that any diagnosed back disorder had its onset in or is otherwise related to the Veteran's period of active service. (b.) Whether it is at least as likely as not (probability of 50 percent or more) that that any diagnosed back disorder (i) manifested to a compensable degree within one year March 11, 1970, or (ii) was noted during service with continuity of the same symptomatology since service. The clinician must discuss the Veteran's post-service reports of symptoms. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. After completing directive # 1, obtain an addendum opinion from an appropriate clinician regarding nature and etiology of any diagnosis of a gastrointestinal disorder including gastroesophageal reflux disease (GERD), and other than an ulcer disorder. An in-person examination is not required unless deemed necessary by the clinician. The clinician should review the virtual file, including a copy of this Remand. The clinician is to address: (a.) Whether it is at least likely as not (probability of at least 50 percent or more) that any gastrointestinal disorder had its onset in or is otherwise related to the Veteran's period of active service. (b.) Whether it is at least as likely as not (probability of 50 percent or more) that any gastrointestinal disorder is proximately due to or the result of a service-connected disability, to include but not limited to PTSD. (c.) Whether is it as likely as not that any gastrointestinal disorder is aggravated (increased in severity beyond the natural progression) by a service-connected disability, to include but not limited to PTSD. The clinician must specifically address whether the Veteran's PTSD led to alcohol use that has aggravated his gastrointestinal disorder. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. (Continued on the next page) If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David Han 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.