Citation Nr: 21066725 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 16-11 874 DATE: November 2, 2021 REMANDED Entitlement to service connection for gastrointestinal reflux disease (GERD), to include as secondary to service-connected disability is remanded. Entitlement to service connection for a back condition is remanded. Entitlement to service connection for left ear hearing loss is remanded. Entitlement to a compensable disability rating for service-connected right ear hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1971 to February 1978 in the United States Army. The claims were most recently before the Board in August 2019. Unfortunately, there has not been substantial compliance with the remand directives and another remand is required. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for GERD, to include as secondary to service-connected disability. 2. Entitlement to service connection for a back condition. The claims are remanded again to obtain adequate medical opinons. The prior remand for GERD directed that the medical opinion address whether the GERD was caused or aggravated by the Veteran's service-connected disabilities, to include medication used to treat those disabilities. The January 2020 VA examiner concluded it was less likely than not that the diagnosed GERD was caused or aggravated by the Veteran's ischemic heart disease. However, the rationale in is inadequate because the examiner referenced only one medication, Metoprolo, but did not indicate whether that is a medication prescribed to the Veteran and if so whether it is for a service-connected disability. The January 2020 VA opinion on the back is also inadequate. The examiner offered a negative nexus opinion, but the rationale is solely based on the lack of continuity of care between an in-service back injury and the Veteran's current condition The examiner failed to address the Veteran's sworn testimony regarding ongoing back pain and self-treatment since active duty service as directed by the Board. 3. Entitlement to service connection for left ear hearing loss is remanded. The claim is remanded for an adequate medical opinion. The January 2020 VA opinon is inadequate for the same reasons the Board identified in the prior remand. The examiner offered a negative nexus opinion based on normal hearing at separation. In addressing the presumption of soundness, the examiner did not address the entrance examination. 4. Entitlement to a compensable disability rating for service-connected right ear hearing loss is remanded. The January 2020 VA examiner stated that they could not test the Veteran's right ear due to severe pain at any level above 60 decibels. However, the examiner did not clarify the nature of the pain (temporary vs. chronic) or whether the pain was a manifestation of the Veteran's right ear hearing loss. The Board finds that further opinion is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the likely etiology of the Veteran's GERD. Copies of all pertinent records must be made available to the examiner for review. The examiner must answer the following: (a) Is it at least as likely as not that the GERD is etiologically related to his active service? The examiner should consider and discuss as necessary the Veteran's STRs noting treatment for an upset stomach and possible reflux. (b) Is it at least as likely as not that the GERD is (i) caused by the medication taken for any of his service-connected conditions to specifically include his service-connected heart condition? (c) Is it at least as likely as not that the GERD is aggravated by (defined as any increase in disability) any medication taken for a service-connected disability, to include his service-connected heart disability? whether the Veteran's treatment for ischemic heart disease includes Metoprolol and the previous examiner's statement regarding exacerbation of GERD by Metoprolol. 2. Obtain an addendum opinion from an appropriate clinician on the likely etiology of the Veteran's back disability. Copies of all pertinent records must be made available to the examiner for review. The examiner must answer the following: (a) Is it at least as likely as not that regarding that the back condition is at least as likely as not related to the Veteran's documented in-service back injury? The examiner should consider and discuss as necessary the Veteran's credible statements that his back had hurt consistently since his active service and that he self-treated his pain rather than seek medical attention. A complete rationale must be provided for any opinion offered. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the (i) current severity of his service-connected right ear hearing loss and (ii) the likely etiology of any diagnosed left ear hearing loss disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. If it is not possible for the examiner to provide the results of the Veteran's audiological testing to including speech discrimination score, they must provide an explanation for this conclusion and state whether these results will be able to be obtained in the future. The examiner must also provide an opinion as to the following: (a) Identify all current findings related to the severity of the service-connected right ear hearing loss. If the examiner is unable to test right ear hearing acuity due to pain, they should identify the nature of the pain and whether it is a symptoms to the service-connected hearing loss. (b) Did a left ear hearing loss disability clearly and unmistakably (i.e., it is undebatable) exist prior to the Veteran's active service that began in 1971? The examiner should consider and discuss as necessary January 1971 enlistment examination. (c) If the answer to (b) is yes, does the evidence clearly and unmistakably show (i.e., it is undebatable) that the left ear hearing loss was not aggravated by service or that any increase in disability was due to the natural progression of the condition? Please identify such evidence with specificity. (d) If the answer to either (b) or(c) is no, is it at least as likely as not that left ear hearing loss disability had its onset in service? In answering this question, the examiner must consider that in-service noise exposure in the form of gun fire and rocket fire has been conceded. (e) If the answer to (d) is no, is it at least as likely as not the left ear hearing loss is (i)cause by or (ii) aggravated by (defined here as any increase in disability) the service-connected right ear hearing loss? A complete rationale must be provided for all opinions offered. 4. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P.S. McLeod 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.