Citation Nr: 21068703 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 13-22 900 DATE: November 12, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to herbicide exposure or as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a circulatory or vascular disability (claimed as heart and circulation problems), to include as secondary to service-connected PTSD and diabetes mellitus, is remanded. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II is remanded. REASONS FOR REMAND The Veteran had active service from September 1966 to September 1968. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2015, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video conference hearing. A transcript of his testimony is of record. These matters were last before the Board in December 2020, when they were remanded for additional development. 1. Entitlement to service connection for GERD, to include as due to herbicide exposure ras secondary to service-connected PTSD, is remanded. 2. Entitlement to service connection for a circulatory or vascular disability (claimed as heart and circulation problems), to include as secondary to service-connected PTSD and diabetes mellitus, is remanded. 3. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II is remanded. As an initial matter, there has not been substantial compliance with the prior remand directives. The October 2018 Board decision directed that Vista Imaging records, which were noted to have been scanned into VistA Imaging in a July 18, 2013 and September 1, 2010 VA record entries, be associated with the claim file. It does not appear that the records were obtained. As the records were scanned into VA's VistA Imaging record system requests must continue until the agency of original jurisdiction (AOJ) determines that the records sought do not exist or that further efforts to obtain them would be futile. As no such determination was made, there has not been substantial compliance with the prior remand directives and another remand is required. The October 2018 Board decision requested an addendum opinion addressing whether the Veteran's GERD was secondary to his service-connected PTSD or any medication taken for his PTSD. An addendum opinion was obtained in October 2019. The clinician opined that the Veteran's GERD was not caused or aggravated by his service-connected disabilities because his list of service-connected conditions did not contain any diagnoses that would affect the esophagus. The clinician also noted that neither of the Veteran's PTSD medications are high risk for causing GERD. The clinician's rationale was conclusory and did not address the treatise evidence cited by the representative regarding the relationship between GERD and PTSD and the side effects of Venlafaxine. Additionally, the clinician did not address the Veteran's contention regarding aggravation of his GERD by the medications taken for his service-connected PTSD. Accordingly, an addendum opinion is required. The evidence indicates there may be outstanding relevant VA treatment records. A March 2, 2021 VA treatment record indicates that the Veteran was to return for a follow up appointment on May 28, 2021 and June 30, 2021. VA treatment records after May 25, 2021 have not been associated with the claims file. Additionally, VA record entries from August 19, 2016, June 29, 2018, June 4, 2019, June 26, 2020 VA records note that records from Alabama Department of Public Safety driver examinations were scanned into VistA Imaging. An August 10, 2018 VA record indicates that a July 7, 2018 endocrinology record from Dr. Jackson had been scanned into VistA Imaging. A July 3, 2018 VA record notes that a July 3, 2018 electromyography (EMG) was scanned into VistA Imaging. VA records from June 8, 2018, September 6, 2018, and August 21, 2019 note that May 24, 2018, September 6, 2018, and August 21, 2019 optometry records had been scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. Accordingly, a remand to obtain the records is required. As noted in the October 2020 Appellate Brief, further clarification is required to determine whether the Veteran's diabetic management involves regulation of activities. In pertinent part, the VA examination reports, and treatment records consistently indicate that regulation of activities was not required. See VA examination reports from August 2021 and August 2016. Additionally, treatment records from Dr. Jackson stressed the importance of regular exercise for glycemic control and/or that the Veteran's hyperglycemia was improved with exercises. See e.g., November 18, 2020, August 12, 2020, May 1, 2019, and October 26, 2018. Nevertheless, a January 18, 2021 statement from Dr. Jackson stated that the Veteran had "to modify his physical activity level to prevent hypoglycemia." Considering the above, further clarification is required to determine whether the Veteran's diabetes management requires regulation of activities, which is defined as avoidance of strenuous occupational and recreational activities. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (2020) (defining the term within the criteria for a 100 percent rating). Regarding the Veteran's circulatory / vascular claim, the record indicates that the Veteran is diagnosed with peripheral vascular disease (PVD) and hypertension. While an opinion regarding the Veteran's PVD was obtained in May 2021 it only addressed direct service connection. It did not address the Veteran's July 2009 assertion that his circulatory / vascular condition was secondary to his service-connected PTSD and diabetes with complications. Regarding his hypertension, the Board cannot make a fully informed decision on the issue because no VA clinician has opined whether the Veteran's hypertension is related to service and/or his service-connected PTSD and diabetes. Accordingly, an addendum opinion is required. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records dated since May 25, 2021 as well as the VistA Imaging records referenced in the September 1, 2010, July 18, 2013, August 19, 2016, June 8, 2018, July 3, 2018, August 10, 2018, September 6, 2018, June 29, 2018, June 4, 2019, August 21, 2019 and June 26, 2020 VA record entries. If any such records are determined to be unavailable, issue a formal finding of unavailability and notify the Veteran of this fact. 2. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's -diabetes mellitus. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should state whether the Veteran's diabetes mellitus requires regulation of activities. The clinician is advised that regulation of activities is defined as the avoidance of strenuous occupational and recreations activities. In so opining, the clinician should reconcile the conflicting evidence, including the treatment records from Dr. Jackson consistently indicating the importance of regular exercise for glycemic control and the January 18, 2021 statement from Dr. Jackson notes that the Veteran had "to modify his physical activity level to prevent hypoglycemia." If the clinician finds that the Veteran's diabetes mellitus requires regulation of activities, the clinician should state when the Veteran's disability necessitated regulation of activities. A complete rationale should be provided for all opinions and conclusions expressed. 3. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's GERD. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's GERD was caused by the service-connected PTSD or any medication taken for the Veteran's PTSD. (b.) Whether it is at least as likely as not that the Veteran's GERD is worsened beyond natural progression (aggravated) by his service-connected PTSD or any medication taken for the Veteran's PTSD. If the clinician finds that the Veteran's GERD was aggravated by his service-connected PTSD, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the GERD. The clinician should address the treatise evidence cited by the representative regarding the relationship between GERD and PTSD and the side effects of Venlafaxine. The clinician should also address the July 22, 2016 statement from Dr. Sherrod noting that a relationship between the Veteran's GERD and PTSD "is conceivable, based on potential contribution of psychological stressors....[and] such a relationship cannot be entirely excluded." A complete rationale should be provided for all opinions and conclusions expressed. 4. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's circulatory / vascular claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that circulatory / vascular disability had its onset during service or is otherwise related to service, to include the Veteran's in-service herbicide exposure. (b.) Whether it is at least as likely as not (50 percent probability or greater) that circulatory / vascular disability was caused by the service-connected PTSD or diabetes mellitus with peripheral neuropathy and erectile dysfunction. (c.) If not caused by the service-connected PTSD or diabetes mellitus with peripheral neuropathy and erectile dysfunction, is it at least as likely as not that the Veteran's circulatory / vascular disability is worsened beyond natural progression (aggravated) by his service-connected PTSD or diabetes mellitus with peripheral neuropathy and erectile dysfunction? If the clinician finds that the Veteran's circulatory / vascular disability was aggravated by his service-connected PTSD or diabetes mellitus with peripheral neuropathy and erectile dysfunction, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the disability. In rendering the above requested opinions, the clinician must address the documented diagnoses of PVD and hypertension. In addressing secondary service connection, the clinician should address the treatise evidence cited by the representative regarding the side effects of Venlafaxine. A complete rationale should be provided for all opinions and conclusions expressed. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Anderson 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.