Citation Nr: 21068894 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 15-33 714 DATE: November 15, 2021 REMANDED Entitlement to service connection for an ulcer condition, to include as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1963 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in June 2021. The Board remanded the matter for additional development. Unfortunately, for the reasons discussed below, another remand is required. This case has been advanced on the docket pursuant to 38 C.F.R. § 20.900. Entitlement to service connection for an ulcer condition, to include as secondary to a service-connected disability. Remand is required for an adequate examination. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In its June 2021 remand directives, the Board sought a new VA examination to determine the nature and cause of any diagnosed ulcer. Specifically, the Board sought the identification of any and all ulcer conditions. If any diagnostic findings contradicted evidence in the record, the clinician was to reconcile the differences, including if previously documented diagnoses were no longer applicable. Additionally, the Board requested adequate opinions on whether it was at least as likely as not that any diagnosed ulcer condition was caused by or aggravated by a service-connected disability, including coronary artery disease (CAD). The Veteran was afforded a VA examination in August 2021. The examiner then provided opinions as to direct and secondary service connection of the Veteran's ulcers. However, the Board finds the clinician did not follow the Board remand directives, nor did he provide adequate examinations. Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). As mentioned above, the Board wished any previously documented diagnoses that were deemed no longer applicable be reconciled. In the August 2021 examination and opinions, the examiner only addressed the duodenal ulcer, but did not discuss the other diagnoses of record, including a gastric ulcer. On whether it was at least as likely as not the Veteran's ulcers were aggravated by his CAD, the clinician found it less likely than not, stating, "[a]fter a thorough search of the Veteran's c-file[,] both of his conditions[,] his ulcer and his coronary artery disease (claimed as heart disease due to Agent Orange exposure)[,] were service connected at the same time[,] 12/07/2010[,] and it does not say which condition he had first to cause one condition to possibly aggravate the other condition. Therefore[,] it is impossible to tell and therefore as less as likely as not (50 percent or greater probability) the Veteran's ulcer aggravated beyond its natural progression by his/her service-connected coronary artery disease (claimed as heart disease due to Agent Orange exposure). This opinion is based on an inaccurate factual predicate, as the Veteran is not service-connected for his ulcers. Furthermore, service connection is a legal determination that should not have an impact on the medical determination of whether one disability aggravates or causes another disability. Additionally, the clinician's opinion fails to address and discuss positive evidence of a relationship between the Veteran's CAD and his ulcers found in a January 2013 private treatment letter. The letter showed the Veteran underwent a coronary artery bypass grafting and the clinician was surprised by a bleeding ulcer. For the above reasons, the Board finds that a remand is warranted. The matters are REMANDED for the following action: 1. Please note that this Veteran's case has been advanced on the docket and, by law, all remanded claims must be processed expeditiously. 2. Schedule the Veteran for an examination by a gastroenterologist or other appropriate clinician other than the clinician who performed his August 2021 VA examination to determine the nature and etiology of any ulcer. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please identify any and all ulcer conditions. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record. If any previously documented diagnoses, such as gastric ulcers, are no longer applicable, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) Is it at least as likely as not (a 50 percent probability or greater) that any diagnosed ulcer condition was incurred in or due to active service? (c.) Is it at least as likely as not (a 50 percent probability or greater) that any diagnosed ulcer condition was caused by a service-connected disability? (d.) Is it at least as likely as not (a 50 percent probability or greater) that any diagnosed ulcer condition was aggravated by a service-connected disability? All answers to the questions listed above must be supported by a clear rationale. The examiner is asked to explain in detail the underlying reasoning for his or her opinion, to include citing to relevant evidence, supporting factual data, prior medical opinions, and medical literature, as appropriate. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must explain why a more definitive response is not possible or feasible. In other words, merely saying he or she cannot respond will not suffice. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee Feldman, Associate 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.