Citation Nr: 21066349
Decision Date: 10/29/21	Archive Date: 10/29/21

DOCKET NO. 17-32 736
DATE: October 29, 2021

REMANDED

Entitlement to service connection for acid reflux disease including as due to an undiagnosed illness is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 1998 to September 2006 and from February 2007 to November 2007.  He served in the Southwest Asia Theater of operations from April 2007 to October 2007.

The Veteran submitted his claim for service connection for acid reflux in September 2015.  At his July 2021 hearing the Veteran reported that his acid reflux began while he was stationed in Kuwait.  He testified that he has had acid reflux symptoms ever since service.  

The Veteran's VA treatment records show current continuing treatment for acid reflux and gastroesophageal reflux disease (GERD). 

The Veteran's claim must be remanded to obtain an adequate VA medical opinion.  The March 2016 negative VA medical opinion is based on an incomplete medical history and is thus inadequate for deciding the Veteran's claim.  The VA examiner detailed the Veteran's medical history, but when she discussed the Veteran's service treatment records (STR) she did not report that the Veteran was prescribed Maalox in August 2005, she did not report that the Veteran was prescribed antacid in September 2007, and she did not report that on his October 2007 post deployment health assessment the Veteran reported frequent indigestion.  The Veteran must be provided a new VA medical opinion that considers the Veteran's complete medical history.   

The matters are REMANDED for the following action:

1. Afford the Veteran for a VA examination to determine whether any gastrointestinal disorder found on examination, to include acid reflux disease and gastroesophageal reflux disease (GERD), arose in or is related to service.  Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, and all pertinent pathology should be noted in the examination report.

Following review of the claims file and an examination of the Veteran, the examiner should provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that any currently diagnosed gastrointestinal disorder, to include acid reflux disease and GERD, is related to the Veteran's active duty service.

The examiner should cite to the medical and competent lay evidence of record, including the Veteran's statements, and provide a complete rationale for the opinion given, based on the examiner's clinical experience, medical expertise, and established medical principles.  In discussing the Veteran's STR, the examiner should note that the Veteran was prescribed Maalox in August 2005, that the Veteran was prescribed antacid in September 2007, and that on his October 2007 post deployment health assessment the Veteran reported frequent indigestion.  

If the Veteran does not report for the examination, the examiner should provide the requested opinion based on a review of the claims file.

 

 

G. A. WASIK

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	R. E. Jones, 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.