Citation Nr: 21075896 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 18-07 138 DATE: December 21, 2021 REMANDED Entitlement to service connection for a gastrointestinal disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from January 1978 to April 1993. This appeal has a long procedural history. It comes before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, November 2020, and June 2021, the Board remanded this claim to the RO for additional development. Having reviewed the record evidence, and although the Board is reluctant to contribute to "the hamster-wheel reputation of Veterans law" by remanding this claim again, additional development is required before the underlying claim can be adjudicated on the merits. Cf. Coburn v. Nicholson, 19 Vet. App. 427, 434 (2006) (Lance, J., dissenting) (finding that repeated remands "perpetuate the hamster-wheel reputation of Veterans law"). Per the June 2021 Board remand, an addendum opinion was provided to determine the nature and etiology of the Veteran's gastrointestinal disability in July 2021. The examiner opined that the Veteran's Hirschsprung's Disease was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that it is it is less likely than not that the Veteran's gastroesophageal reflux disease (GERD) is related or attributable to his service. Unfortunately, despite directing that the RO obtain a medical opinion from a "medical doctor" in December 2018, November 2020, and June 2021, the July 2021 opinion was provided by a nurse practitioner. In August 2021, addendum opinions were provided by a medical doctor, Dr. S.R.D. After reviewing the claims file, Dr. S.R.D. found that there was no evidence to warrant diagnoses for a stomach or intestines condition. Dr. S.R.D. noted that the Veteran has had a pancreatic tumor, status post Whipple surgery, which is outside the scope of the gastrointestinal examination. Unfortunately, Dr. S.R.D. did not reconcile the finding of no diagnoses with conflicting objective medical evidence of record indicating multiple gastrointestinal diagnoses, specifically: (1) a June 2005 diagnosis of neoplasm in the head of his pancreas by Dr. J.P.; (2) a August 2014 diagnosis of distal colonic diverticulosis record in VA treatment records; (3) August 2014 diagnoses of Barrett's esophagus, diverticulosis, and pancreatic cyst recorded in an intestinal conditions VA examination; and (4) November 2019 diagnoses of gastrointestinal bleed, Hirschsprung's disease, diverticulosis, and small bowel resection associated with bowel obstruction recorded in VA intestinal surgery and intestinal conditions VA examinations. As such, a remand is required for a new medical opinion. The Board acknowledges the difficulty/ies faced by the RO in obtaining an opinion from an appropriately qualified "medical doctor" in light of the prior remand directives. The Board also acknowledges that the RO achieved substantial compliance with the prior remand directives in obtaining an opinion from Dr. R. S. D. in August 2021. As noted above, however, that opinion is inadequate for VA adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Forward the claims file and a copy of this REMAND to an appropriately qualified clinician for an opinion concerning the nature and etiology of the Veteran's gastrointestinal disability. If possible, this opinion should be provided by a clinician who has not provided an opinion previously. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to identify any current gastrointestinal disability/ies experienced by the Veteran. The clinician next is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's Hirschsprung's Disease was aggravated during active service. In his or her response, the clinician is asked to specifically discuss the underlying medical cause for the Veteran's hospitalization in 1991 for small bowel obstruction and, to the extent possible, reconcile it with the VA examiner's opinion in 2015 that the bowel obstruction in service was a natural progression of the Hirschsprung's Disease versus a 2015 Disability Benefits Questionnaire (DBQ) note that a Whipple Procedure found adhesions and internal hernias. For any gastrointestinal disability other than Hirschsprung's Disease, including gastroesophageal reflux disease (GERD), colonic diverticulosis, small bowel resection for gastrointestinal bleeding with possible history of small arteriovenous malformations (AVMs) and cystic lesion on pancreas experienced by the Veteran, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disorder began during service or otherwise is related to service. In his or her response, the clinician is asked to discuss whether there is any medical reason to accept or reject the Veteran's belief that his report of gastrointestinal symptoms during and after active service represented the onset of these disorders during service. In providing these opinions, the clinician's attention is directed towards the following: (1) a December 1977 entrance examination noting questionable pyloric stenosis and history of abdominal surgery at 3 months old; (2) the Veteran's in-service history of treatment for gastrointestinal symptoms variously diagnosed as diarrhea of probable bacterial origin, diarrhea secondary to altered fecal flora, viral gastroenteritis, and small bowel obstruction; (3) an August 11, 2014, VA gastroenterology consultation report summarizing the Veteran's treatment history as well as the type of surgery performed as an infant; and (4) the November 2019 VA examination report. A rationale must be provided for any opinion(s) expressed. A separate opinion and rationale should be provided for each gastrointestinal disability currently experienced by the Veteran, if appropriate. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the lack of contemporaneous records documenting complaints of or treatment for a gastrointestinal disability, alone, is insufficient rationale for a medical nexus opinion. The clinician also is advised not to review or rely upon any prior medical opinions found in the record evidence. 2. Review the completed medical opinion(s) and determine whether it complies substantially with the terms of this REMAND. If not, please take appropriate corrective action. 3. Thereafter, readjudicate the appeal. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.N., 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.