Citation Nr: 21077532 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 18-33 231 DATE: December 30, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. INTRODUCTION The Veteran served honorably on active duty in the United States Army during the Peacetime and Gulf War Era, from February 1988 to February 2008, including service in the Southwest Asia Theater of Operations. He is the recipient of the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2016 Rating Decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). When this matter came before the Board in August 2019 it was denied on the merits. Thereafter, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court) and, pursuant to a Joint Motion for Partial Remand (JMPR) entered into between the parties, the Court issued its July 2020 Order remanding the matter for action consistent with the terms of the JMPR. When the matter returned to the Board in December 2020 it was remanded for additional development. The additional development has been conducted and the matter returns to the Board for further appellate review. The Board's most recent decision also remanded the issue of entitlement to service connection for hypertension, which was subsequently granted by Rating Decision dated August 2021. This represents a full grant of the benefit sought and, as such, the issue is no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). While further delay is regrettable, for the reasons set forth below, the Board finds remand is again required to ensure substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). REASONS FOR REMAND Entitlement to service connection for GERD is remanded. The record raises several theories for entitlement to service connection for GERD. Essentially, the Veteran's July 2016 written statement attributes his "persistent and unexplained chest pain (previously claimed as GERD)" to taking pyridostigmine bromide (PB) as well as "exposure to pesticides, and possible Depleted Uranium (DU)" during active duty service. According to his attorney's May 2018 written arguments, research shows "a likely link between GERD and service in the 1990 Gulf War ... [and] ... between GERD and [service-connected] PTSD," and cites medical articles as support. Further, as addressed in the July 2020 JMPR and the Board's December 2020 remand decision, October 2001 service treatment records (STRs) reflect "complaints of pain in heart for two weeks and parasternal chest pain." The JMPR determined that the February 2018 VA examination report was inadequate as it failed to "address direct service connection when such was reasonably raised by the record." Moreover, as the Board's prior remand states, "the examination did not address the Veteran's reports at the examination of intermittent episodes of heartburn initially in service." As a result, the Veteran was afforded another VA examination in July 2021 and a medical nexus opinion was procured. For the following reasons, the Board finds the VA examination reports inadequate for adjudication purposes and, consequently, remand is again required to ensure substantial compliance with the prior remand directives. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall, 11 Vet. App. 268. First, according to the VA examiner's reports, the Veteran "notes bouts of acid reflux with foods and indigestion in 2012," and the examiner indicates February 2013 as the date of onset. However, according to a November 2016 VA examination report, the "Veteran states he began having problems with his stomach as early 2002 [sic] while stationed in Fort Knox, KY where he was treated with antacid for a condition that would come and go." Unfortunately, the VA examiner's reports and, most significantly, his opinion rationale fail to address the Veteran's 2016 statement. Moreover, just as the February 2018 VA examiner failed to address the Veteran's statement describing "intermittent episodes of heartburn initially in the service which he attributed to certain foods," the July 2021 VA examiner's opinion is also devoid of such discussion. See Dalton v. Peake, 21 Vet. App. 23 (2007) (noting that a medical opinion which does not consider the Veteran's reports of symptoms and history, even if recorded in the course of the examination, is inadequate). Next, according to the VA examiner's abbreviated opinion rationale, "[t]he medical record ... lacks sufficient information to support GERD that was incurred during the period of active service." The examiner's opinion is conclusory in nature and fails to articulate a reasoned medical analysis in relation to the pertinent evidence of record. See Miller v. West, 11 Vet. App. 18, 22 (2007) (a bare conclusion, even one reached by a healthcare professional, is not probative without a factual predicate in the record); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion is derived from it being factually accurate, fully articulated, and soundly reasoned). As a result, the Board is unable to conclude that the VA examiner applied valid medical analysis to the significant facts of this particular case. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Finally, the VA examiner's reports do not include an opinion addressing the secondary service connection theory of entitlement raised by the record. Accordingly, this matter is REMANDED for the following action: Schedule the Veteran for an in-person VA examination with a physician who has not previously offered an opinion in this matter and possessing the necessary expertise to fully assess and provide an opinion regarding the nature, severity, and likely etiology of the Veteran's GERD including, but not limited to, as due to possible exposure to environmental hazards in the Southwest Asia theater of military operations or secondary to a service-connected disability or disabilities. The examiner must obtain a full history from the Veteran. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable in-service and post-service symptomology and functional limitations. All pertinent symptomology, including when initially manifested and any progression, must be elicited from the Veteran and reported in detail. Based upon a review of all pertinent evidence in the Veteran's claims file including medical treatment and prior examination records, lay statements, and the examination results, the examiner must offer an opinion based upon an accurate medical history with clear conclusions and supporting data as to: (a.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) the Veteran's GERD manifested during active military service or is due to, related to, or otherwise etiologically associated with an in-service injury, event, or illness including, but not limited to, possible exposure to environmental hazards in the Southwest Asia theater of military operations. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) the Veteran's GERD is proximately due to, related to, or otherwise etiologically associated with his service-connected disabilities including, but not limited to, PTSD or sleep apnea. (c.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) the Veteran's GERD has been aggravated by his service-connected disabilities including, but not limited to, PTSD or sleep apnea. The examiner is advised that aggravation does not require a permanent worsening of the condition, but rather, any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase. See Ward v. Wilkie, 31 Vet. App. 233 (2019). In offering the above opinions, the examiner must consider, discuss, and reconcile as necessary all pertinent lay and medical treatment and examination evidence of record including, but not limited to: (a.) STRs dated October 2001 noting complaints of heart and left parasternal chest pain; (b.) November 2016 VA examination report noting the "Veteran states he began having problems with his stomach as early 2002 [sic] while stationed in Fort Knox, KY where he was treated with antacid for a condition that would come and go"; and (c.) February 2018 VA examination report noting the Veteran's statement describing "intermittent episodes of heartburn initially in the service which he attributed to certain foods." The examiner is advised that the mere absence of evidence does not equate to unfavorable evidence. The Veteran's lay statements and reports of onset and symptomology must be considered and discussed. A complete and thorough rationale for all opinions expressed, with references to pertinent evidence of record and, as warranted, relevant medical literature must be provided. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.