Citation Nr: 21073624 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 20-22 986 DATE: December 9, 2021 REMANDED Entitlement to a disability rating in excess of 30 percent for a stomach disorder, claimed as gastroesophageal reflux disease (GERD) with diverticulitis, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1965 to October 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In an August 2020 decision, the Board, in part, granted a disability rating of 30 percent, but not higher, for the Veteran's GERD disability. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). As set forth in a July 2021 Joint Motion for Partial Remand (JMR), the parties requested that the Court vacate the portion of the August 2020 Board decision that denied a disability rating in excess of 30 percent for GERD and remand the case for actions consistent with the JMR. The parties agreed the Board erred when it failed to provide an adequate statement of reasons or bases. Specifically, the Board erred when it did not address whether the Veteran's esophageal symptoms warranted a higher or separate rating under diagnostic codes 7203 and 7204 or other potential applicable diagnostic codes and the Board did not adequately address the standard for "productive of severe impairment of health" in terms of the evidence of record. In September 2019, the Veteran underwent an esophageal condition VA examination. The examiner noted the Veteran had three to four spasms a week, usually while drinking. In May 2020, the Veteran reported esophageal spasms with reflux three to four times per day to the point he must stop all activity, to include he has to stop eating while eating a meal due to the spasm. See May 2020 VA Form 9 Appeal to the Board. Recent treatment records indicate the Veteran continues to have trouble with reflux and gets frequent esophageal spasms which lasts seconds but takes his breath away. See November 2020 CAPRI records received in May 2021. As the Veteran's contentions have not been addressed and the record suggests that the Veteran's disability picture has changed since his last examination, a new VA examination is warranted to determine the current severity of his GERD. Additionally, the parties agreed, that the record showed a potentially relevant record of a May 2018 GERD esophagogastroduodenoscopy (EGD) was not associated with the claims file and the Board should ensure the report is incorporated into the claims file. The record contains a May 2018 treatment note stating the EGD revealed small hyperplastic polyps, no further evaluation is needed, and no esophagitis or Barrett's disease was found. Upon remand, the RO should attempt to obtain the full report. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file any outstanding VA treatment records, to include the May 2018 GERD EGD report. If the records are not available, the Veteran should be notified, and the claims file annotated as such. 2. Schedule the Veteran for a VA examination to determine the current nature and severity of his GERD. The claims file should be made available to and reviewed by the examiner. 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. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.V. Palatt, 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.