Citation Nr: 21070033 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 15-03 267 DATE: November 22, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected lumbar spondylotic changes and degenerative disc disease, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1965 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2018 and July 2021, the Board remanded the case to the RO for evidentiary development. Following the requested development, a supplemental statement of the case (SSOC) was issued in September 2021. A September 2021 rating decision granted the Veteran's claim for service connection for allergic rhinitis and assigned an initial rating. As this decision represents a full grant of the benefits sought with respect to this claim for service connection, such issue is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). 1. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran essentially contends that he developed bilateral hearing loss as a result of his exposure to noise excessive noise during his period of active duty. The Veteran maintains that he was exposed to noise from cannons while training for combat in the heavy tanks. As such, he maintains that his current hearing loss is a direct result of his military service. A VA etiology opinion were obtained in August 2021. In an October 2021 Informal Hearing Presentation, the Veteran's representative essentially argued that the Veteran experienced delayed onset hearing loss due to a progressive damage process from in-service acoustic trauma. The representative then cited to multiple journal articles and internet articles that purportedly support his proposition. This literature was not addressed in the most recent VA examination. On remand, an addendum opinion should be obtained that considers this identified literature. 2. Entitlement to service connection for GERD is remanded. The Veteran generally contends that he developed GERD as a result of service. Alternatively, the Veteran also maintains that his gastrointestinal disorder, diagnosed as GERD, developed as a result of medications prescribed for his service-connected disabilities. Post-service treatment records reflect diagnoses of GERD in March 2014 and October 2019. A VA etiology opinion was obtained in August 2021. The examiner opined that the Veteran's GERD was less likely as not caused by or proximately due to his service-connected low back disability, right knee disability, right hip disability, or tinea pedis, to include any medications used to treat these service-connected disabilities. The examiner noted that the Veteran's GERD could not have been secondary to pain control medications because he is allergic to aspirin and its usage was then and now contraindicated, that the prescribed acetaminophen alternative is not a cause nor deteriorates a GERD condition and that the Veteran's active medication profile does not include medications that irritate stomach mucosae nor esophageal mucosae. In an October 2021 Informal Hearing Presentation, the Veteran's representative noted that the Veteran was prescribed Synthroid for his service connected thyroid condition and that the Food and Drug Administration (FDA) indicates that the side effects of this medication includes vomiting, nausea, stomach pain and diarrhea. This contention was not addressed in the most recent VA examination. On remand, an addendum opinion should be obtained that considers the impact of this medication. 3. Entitlement to a TDIU is remanded. The Veteran's claim of entitlement to a TDIU is inextricably intertwined with the service connection claim being remanded herein, as the outcome of such claim may impact the TDIU claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Therefore, adjudication of the TDIU claim must be deferred. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain a new addendum etiology opinion to determine the nature and etiology of the Veteran's bilateral hearing loss. The need for further in-person examination is left to the discretion of the examiner. A copy of this remand and claims file must be reviewed. The VA examiner should respond to the following: Is it at least as likely as not that the Veteran's bilateral hearing loss is related to his military service, to include exposure to loud noise? The examiner should specifically address the Veteran's contentions that he experiences delayed onset hearing loss due to a progressive damage process from in-service acoustic trauma. The examiner should also specifically address the medical journal articles and internet articles cited by the Veteran's representative in the October 2021 Informal Hearing Presentation. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Following the receipt of outstanding records, obtain a new addendum medical opinion to determine the nature and etiology of the Veteran's GERD. The need for further in-person examination is left to the discretion of the examiner. A copy of this remand and claims file must be reviewed. The VA examiner should respond to the following: (A) Is it at least as likely as not that the Veteran's GERD was caused by or proximately due to his service-connected (i) low back disability, (ii) right knee disability, (iii) right hip disability, (iv) tinea pedis, (v) rhinitis, (vi) hypothyroidism, (vii) left knee disability or (viii) left hip disability, including any medications used to treat these service-connected disabilities? (B) Is it at least as likely as not that the Veteran's GERD was aggravated (worsened beyond its natural progression) by his service-connected (i) low back disability, (ii) right knee disability, (iii) right hip disability, (iv) tinea pedis, (v) rhinitis, (vi) hypothyroidism, (vii) left knee disability or (viii) left hip disability, including any medications used to treat these service-connected disabilities? The examiner should specifically address the contention and article cited by the Veteran's representative in the October 2021 Informal Hearing Presentation that the Veteran's prescribed Synthroid for his service connected hypothyroidism caused or aggravated his GERD. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Suzie S. Gaston, 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.