Citation Nr: 21077567 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 17-08 665 DATE: December 30, 2021 REMANDED 1. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1982 to July 2002, including service in Southwest Asia. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2015 Department of Veterans Affairs (VA) rating decision. In September 2019 and August 2021, these matters were remanded for additional development. 1. Entitlement to service connection for GERD. The Veteran alleges alternative theories of entitlement to service connection. He contends that GERD is related to environmental exposures while he was deployed to the Southwest Asia theater of operations during the Persian Gulf War or, in the alternative, is secondary to his service-connected disabilities, to include his acquired psychiatric disability and/or irritable bowel syndrome (IBS). The September 2019 Board remand observed that lay statements from the Veteran and fellow service members reflect complaints of gastrointestinal problems in service. The September 2019 Board remand ordered a VA examination to obtain an opinion that addressed whether any current GERD, IBS, abdominal pain, gastrointestinal problems, and functional bloating were related directly to active service or caused or aggravated by the Veteran's service-connected unspecified trauma and stressor related disorder. On December 2019 VA esophageal conditions examination, the Veteran reported that the onset date was in 2010 and that GERD is the same now as it was while he was in the military. In the opinion, the VA examiner noted that the symptoms did not begin until 2010 but did not address the lay reports of symptoms manifesting in service. The examiner explained that GERD could be caused by smoking, eating large meals or eating late at night, eating certain foods, drinking certain beverages, or taking certain medications. The examiner did not address what types of "certain medications" cause/aggravate GERD. Notably, the Veteran's treatment records reflect he has been prescribed medication for his service-connected hypertension, IBS, and unspecified trauma and stressor related disorder. In an October 2020 VA addendum opinion regarding the secondary service connection theory of entitlement, another examiner opined that GERD was not related to the Veteran's service in Southwest Asia and that the records do not indicate that the Veteran's GERD was aggravated beyond normal progression or worsened due to his PTSD. The provider explained the GERD results from obesity, lying flat in bed, eating large meals, and pregnancy. While the provider noted that the diagnosis of GERD is documented well after service and the Veteran's weight gain contributed to his GERD, she reported in the section discussing the etiology of IBS that the "symptoms described by the Veteran and his 'buddies' are credible and as likely as not are related to this Veteran's service in Southwest Asia." The provider does not reconcile the lay statements as to whether it also relates to his current GERD. Additionally, the examiner does not address whether the Veteran's GERD is caused or aggravated by medications he takes for his service-connected disabilities. The August 2021 Board remand ordered a VA medical advisory opinion addressing the etiology of GERD. The examiner was specifically to address whether GERD was secondary (caused or aggravated) by his service-connected IBS disability. The examiner was instructed to consider the Veteran's lay assertions as to the onset and continuity of symptomology. In a September 2021 VA medical opinion, the clinician opined that it was less likely than not that the Veteran's GERD was proximately due to or aggravated beyond its natural progression by the service-connected IBS. The provider appears to base his opinion on an inaccurate review of the record. He notes that in February 2016 that the Veteran did not have an active diagnosis of IBS. However, the November 2020 rating decision awarded service connection for IBS, rated 30 percent effective May 24, 2014 (indicating the disability was active since 2014). Additionally, the provider does not address the lay assertions as to onset and continuity or reconcile the notations by the December 2019 VA examiner of "certain medications" causing GERD. Accordingly, it is inadequate for rating purposes. The December 2019, October 2020, and September 2021 VA examinations are non-responsive to the Board's remand directives, and corrective action is necessary. See Stegall v. West, 22 Vet. App. 268 (1998). 2. Entitlement to TDIU The TDIU claim remains inextricably intertwined with the remanded claim seeking service connection for GERD. Therefore, consideration of the matter is deferred pending development and resolution of that claim. The matters are REMANDED for the following: 1. Arrange for the Veteran's record to be forwarded to an appropriate clinician, other than the September 2021 VA provider, for review and an advisory medical opinion regarding the etiology of his current GERD. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The consulting provider should: (a.) Identify the likely etiology of the Veteran's diagnosed GERD. Specifically, is it at least as likely as not (a 50% or greater probability) that it is etiologically related to his service, to include while the Veteran was deployed to the Southwest Asia theater of operations during the Persian Gulf War. [The rationale must acknowledge (discuss the significance, if any) of the lay statements from the Veteran and fellow service members reflecting continuing complaints of gastrointestinal problems in service.] (b.) If GERD is found to not be directly related to service (and exposures therein), opine further whether it is at least as likely as not that it was caused or aggravated by (increased in severity due to) the Veteran's service-connected disabilities (to include his hypertension, acquired psychiatric disability, and IBS (as well as medication/ treatment for the service-connected disabilities)? [The opinion must address aggravation.] (c.) If a service-connected disability (and/or its treatment) did not cause, but aggravated, GERD, specify, to the extent possible, the degree of disability (symptoms/impairment) that has resulted from such aggravation. (d.) If GERD is determined to not have been incurred in service or caused or aggravated by a service-connected disability, identify the etiology for GERD considered to be more likely (and explain why that is so). A complete rationale for all opinions reached must be provided. 2. Upon readjudication of the remanded claim, and following any further development indicated, readjudicate the TDIU claim considering that determination. L. Baskerville Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.