Citation Nr: 21074994 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 13-05 315 DATE: December 17, 2021 REMANDED Entitlement to a compensable disability rating for duodenal ulcer is remanded. Entitlement to a disability rating in excess of 10 percent for residuals of forearm injury 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 1972 to September 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Most recently, in a January 2018 decision, the Board remanded these issues for additional development, which has not been substantially completed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that, during the pendency of the appeal, in a September 2021 rating decision, the RO granted service connection for a stomach disability, which is a full grant of the benefits sought on appeal; therefore, the issue of service connection for a stomach disability is no longer before the Board. 1. Entitlement to a compensable disability rating for duodenal ulcer, is remanded. The Veteran is seeking a higher disability rating for his service-connected duodenal ulcer. Specifically, he contends that his disability is more severe than reflected by his currently assigned disability rating. See February 2013 Claim (Formal claim based on worsening of conditions). The Veteran alternatively asserts that his ulcer should be rated under a different diagnostic Code, based on the findings in a September 2014 VA esophageal examination which suggest that the Veteran's disability is more accurately described as chronic gastritis. See October 2017 Appellate Br. Turning the evidence of record, in March 2014 the Veteran was afforded a VA examination. The Veteran reported that he had symptoms. The examiner was unable to proceed with the VA examination because Veteran and VA examiner were unable to communicate. See also August 2015 Board Decision; March 2014 Report of General Information. In September 2014, the Veteran was afforded an esophageal condition. The Veteran reported persistent pain in the mid abdomen, described as burning with persistent ache associated with reflux. He reported that symptoms occur about 4 times a year and typically last less than one day. Treatment consists of omeprazole. Symptoms involving persistently recurrent epigastric distress, reflux and sleep disturbance occur 4 or more times a year and typically last less than 1 day. The examiner attributed these to the esophageal condition of hiatal hernia. The examiner reviewed a report of upper gastrointestinal series that was performed in 2011. No ulcer was identified in the report. The Veteran was assessed to have a duodenal ulcer, resolved. The Veteran was also diagnosed with chronic gastritis, which the examiner asserted was a more accurate description of the Veteran's service-connected condition. In a March 2020 VA stomach nexus opinion, the examiner noted that the Veteran noted in 2011 that he had been on medications for ulcers since 1990's, and he was using Omeprazole. An EGD from around that time showed findings suggestive of gastritis but no ulcer. In September 2020 VA stomach examination, which specifically excluded esophageal conditions, the Veteran was not found to have any symptoms or due to duodenum conditions or incapacitating episodes. VA treatment records show a history of bleeding ulcer in March 2007, prior to the period on appeal and peptic ulcer. See, e.g., August 2013 VA Treatment Record. Private treatment records do not show complaints or treatment during the appeal period for a duodenal ulcer. The Veteran has additionally submitted multiple buddy statements indicating that he experienced physical harm and has experienced pain since service. See March 2014 Buddy Statements. Following a review of the evidence of record and the applicable legal criteria, the Board finds that additional development is warranted prior to adjudication of the claim for a higher disability rating for service-connected duodenal ulcer. Specifically, the Board finds that the evidence of record is insufficient and clarification as to the nature of the Veteran's service-connected disability and associated symptoms is necessary to determine the disability rating that most closely approximates the Veteran's disability picture. See Savage v. Shinseki, 24 Vet. App. 259 (2011) (the Board may have a duty to seek clarification of unclear or insufficient medical opinions). Accordingly, a remand for additional development, is warranted. 2. Entitlement to a disability rating in excess of 10 percent for residuals of forearm injury is remanded. The Veteran is seeking a higher disability rating for his service-connected residuals of forearm injury. Specifically, he contends that his disability is more severe than reflected by his currently assigned disability because his elbow condition is related to his service-connected residuals of forearm injury. See October 2017 Correspondence. As noted above, this matter was remanded in January 2018 for additional development. The RO was instructed to obtain muscle injury, wrist, and scar examinations and obtain nexus opinions. Pursuant to the remand directives, in November 2020, the RO obtained new VA examinations and opinions. Unfortunately, the nexus opinion obtained regarding whether the Veteran has an elbow condition related his service-connected residuals of forearm injury is inadequate for adjudicative purposes. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, although the VA examiner opined that the Veteran's elbow condition was not caused by the Veteran's service-connected disability the examiner failed to opine on whether the Veteran's elbow condition was aggravated beyond natural progression by the Veteran's service-connected disability. As such, remand for an addendum VA opinion is warranted. The Board additionally notes that the Veteran has submitted new medical literature regarding the nature of elbow conditions after the most recent VA examination and opinion. In providing a new nexus opinion, the VA examiner should consider this new evidence. See October 2021 Correspondence. 3. Entitlement to a TDIU due to service-connected disabilities is remanded. The Board finds that the issue of entitlement to a TDIU is inextricably intertwined with the issue being remanded. 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). Consideration of entitlement to a TDIU must, therefore, be deferred until the intertwined issue is either resolved or prepared for appellate consideration. See id. The matters are REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records, and any private treatment records identified by the Veteran. All records and/or responses received should be associated with the claims file. 2. After all outstanding treatment records have been associated with the claims file, obtain a VA examination for esophageal conditions, from an appropriate clinician, regarding the nature and severity of the Veteran's duodenal ulcer. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. The need for a VA examination for stomach disabilities, or other warranted VA examination, is left to the discretion of the clinician selected to write the opinion. The VA examiner/clinician should address the following: (a.) Identify the nature of the Veteran's disability. In doing so, the examiner should address the September 2014 VA examination indicating that Veteran's duodenal ulcer is more accurately described as chronic gastritis. (b.) Identify any symptoms associated with the Veteran's identified service-connected disability. In doing so, the examiner should note that the Veteran has a separate service-connected disability: gastric polyps associated with duodenal ulcer. The examiner should, to the extent possible and to prevent possible additional Remands, differentiate which symptoms are attributed to (i) the identified service-connected disability on appeal, to include any resolved duodenal ulcer and/or chronic gastritis, and which symptoms are attributable to (ii) the Veteran's service-connected gastric polyps. The examination report must include a complete rationale for all opinions provided. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiners should explain why an opinion cannot be provided without resorting to speculation. 3. Obtain a VA addendum medical opinion, from an appropriate clinician, to determine the nature and etiology of the Veteran's right forearm disability. If an opinion cannot be obtained without an examination, then a VA examination should be afforded to the Veteran. The examiner should opine on the following: (a.) Is it at least as likely as not (50 percent or greater probability) the Veteran's right elbow disability began during service or is related to service, to include as due to his inservice right forearm injury? (b.) Is it at least as likely as not the Veteran's right elbow disability is proximately due to his residuals of right forearm disability? (c.) Is it at least as likely as not the Veteran's right elbow disability is aggravated beyond its natural progression by his right forearm disability. In doing so, the examiner should address the Veteran's lay assertions of record and submitted medical literature, to include medical literature submitted in October 2021. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Then readjudicate the TDIU issue on appeal. If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Kaufer, 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.