Citation Nr: 21077100
Decision Date: 12/28/21	Archive Date: 12/28/21

DOCKET NO. 18-03 798
DATE: December 28, 2021

REMANDED

Entitlement to an evaluation in excess of 30 percent for gastroesophageal reflux disorder (GERD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 2000 to July 2002.

The Veteran testified at a hearing before the undersigned in December 2021. The transcript from the hearing has not yet been associated with the file, as the appeal is being processed under the Board's "One Touch" program. A copy of the transcript will be added to the record in the ordinary course of business.

Entitlement to an evaluation in excess of 30 percent for GERD is remanded.

The claim is remanded to obtain updated treatment records and a current examination.  

At the hearing, the Veteran reported that his disability had become more severe since the last VA examination in September 2015 examination. He also testified that he experiences multiple secondary problems associated with his GERD and the medications for GERD, including vitamin deficiencies, anemia, dry and scratchy throat, and hoarseness. The examination on remand must identify all manifestations of the service-connected GERD, including the reported secondary symptoms, and the current severity. 

Updated VA treatment records should be obtained. See 38 C.F.R. § 3.159. The Veteran receives consistent treatment from VA; however, the last VA medical records associated with the record are dated in September 2020. 

VA records include notations that private medical reports were scanned into VistA Imaging. Those records are not included within the record and should be obtained on remand. 

The matters are REMANDED for the following action:

1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his GERD. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records dated since September 2020 as well as all records scanned into VistA Imaging. If any requested records are unavailable, the Veteran should be notified of such.

2. After completion of the above, schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by an appropriate clinician to determine the current severity of his service-connected GERD. The examiner must complete the corresponding VA disability benefits questionnaire (DBQ), provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria.

(a) The examiner must specifically address the following: identify all symptoms and secondary problems the Veteran claims may be associated with his GERD or the medications for GERD; specifically, any vitamin deficiencies, anemia, dry and scratchy throat, and hoarseness, caused by GERD and the medications for GERD.

(b) For any secondary problem identified, the examiner must specifically state whether it represents a symptom of the already service-connected GERD or is a separately diagnosed disability.  

Consider all pertinent lay and medical evidence. Provide a clear and comprehensive rationale for any conclusions. If any requested opinion cannot be provided without resort to speculation, court cases require the examiner to explain why the opinion cannot be offered, and to state whether the inability is due to the absence of evidence or to the limits of scientific or medical knowledge.

 

 

M.E. LARKIN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Robert J. Burriesci, 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.