Citation Nr: 21066695 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-51 817 DATE: November 1, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD), as secondary to service-connected disability, to include obesity as an intermediary condition, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1975to February 1995. The Board finds that the opinion obtained by the RO regarding the Veteran's claim for service connection for GERD, as secondary to his service-connected physical disabilities, is inadequate, and remand is required to obtain an addendum opinion for the VA to fulfill the duty to assist the Veteran. The Board notes that the VA's statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is inadequate, as it is here, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). In accordance with the directives from the Board's last remand, the Veteran was afforded a VA examination in August 2021 to assess the nature and etiology of his GERD. Per the Board's remand directives, the VA examiner was asked to opine whether the Veteran's GERD was caused or aggravated his already service-connected conditions. As part of any findings, the examiner was asked to explicitly speak to the effects of the Veteran's medications for his service-connected disabilities, and the development of obesity, on the development or aggravation of GERD. A close review of the August 2021 opinion, however, reveals that such analysis and findings were incomplete, and remand is required. Specifically, with regards to the development of GERD as a result of obesity as an intermittent condition caused by his physiological disabilities, the examiner's rationale and opinion to be incomplete. The examiner found that the Veteran's obesity was not caused or aggravated by any of the Veteran's service-connected physiological disabilities, to include his back and knees. Indeed, the examiner's rationale noted that obesity was "strictly" due to caloric intake and not affected by exercise and/or activity. As such, the examiner concluded that as a physical ability to move or exercise had no bearing on the development of obesity, and that in turn, the Veteran's service-connected disabilities had no bearing on the Veteran's weight development and GERD. The Board finds that the rationale provided by the VA examiner discussing the development of obesity, as strictly a function of caloric intake, to be incomplete and inadequate. Here, a close review of contemporaneous VA and private treatment records seem to allude to a dichotomous position with regards to the effects of the Veteran's inability to exercise and participate in activities, and the development of his obesity. Indeed, such medical notations were explicitly noted in the 2019 Joint Motion for Remand (JMR), by the United States Court of Appeals for Veteran Claims (Court) for this claim, and also noted in the directives in the last remand. As such, the Board finds that the VA examiner's silence on any of such evidence renders the opinion regarding obesity inadequate. Additionally, the Board also finds that in the examiner's rationale on obesity, the examiner's findings do not cite or speak to the Veteran's case directly, but rather, in general. Indeed, in the entire analysis, the examiner fails to give any specific examples of weight gain, changes specific to the Veteran, or speak to any medical evidence directly linked to the Veteran's treatment during the claims period. The Board finds that such generalized rationale does not speak to the evidence of record, and fails to directly address the Veteran's condition, and as such, remand is required. The matters are REMANDED for the following action: 1. After any outstanding evidence is associated with the claims file, return the claims file to the August 2021 VA examiner, and request a re-review the claims file and respond to the inquiry below. If the examiner is not available, arrange for another appropriate VA examiner to provide an addendum opinion as to the etiology of the Veteran's GERD. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinion: (a) Whether the Veteran's GERD was caused by the Veteran's use of NSAIDs, or other medication used to treat any service-connected disorder. (b) Whether the Veteran's GERD was aggravated, made worse, by the Veteran's use of NSAIDs or other medications used to treat any service-connected disorder. (c) Whether any of the Veteran's service-connected disabilities caused the Veteran to become obese. (d) Whether any of the Veteran's service-connected disabilities aggravated, made worse, the Veteran's obesity. (e) If the examiner fines the Veteran's service-connected disabilities either caused or aggravated the Veteran's obesity, whether the obesity or aggravation of obesity was a substantial factor in causing GERD. (f.) If the examiner finds the obesity or aggravation of obesity was a substantial factor in causing GERD, whether the current disability would not have occurred but for obesity caused or aggravated by the service-connected disabilities. IN ADDITION TO ANY RECORDS ADDED TO THE FILE AS A RESULT OF THE ABOVE-DIRECTED DEVELOPMENT, the examiner's attention is drawn to the following: (1) A VA nursing note, dated May 13, 2019, indicating that Veteran made the statement: "I cannot because of my back and both knee pain[sic]. I had a gym membership, but I had to let it go. I was hurting too bad. I know I need to lose weight and I will as soon as I can have surgery to get rid of the pain." (2) A VA primary care follow-up note, dated April 13, 2017, stating: "Morbid Obesity-Goal less than 30[.] Discussed weight loss through diet and exercise, discussed decreasing portions sizes, tracking calorie intake[.] Discussed the impact obesity has on weight bearing joints[.] Current Barrier/Barriers to exercise: Bil knee pain/lower back." (3) A VA primary care note, dated August 4, 2016, stating: "morbid obesity: veteran has lost weight during clinic interval, he is down 322 to 309. He is receiving steroid injections in spine and has been eating more, difficult to exercise with chronic back pain." (4) A June 2014 VA medical opinion stating the Veteran's GERD "is more likely than not due to obesity and anatomical dysfunction of the esophageal sphincter." (5) A VA primary care follow-up note, dated April18, 2011, indicating: "[t]he patient returns with the following new complaint: R knee painful since the army days. Had arthroscopic surgery. Trying to postpone knee replacement -uses ibuprofen. Limits exercise tolerance and contributes to weight problems." DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ziheng Zhu, 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.