Citation Nr: 21005955 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 16-51 542 DATE: February 3, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent disabled for gastroesophageal reflux (GERD) is remanded. Entitlement to a higher rating for migraine headaches evaluated as noncompensable prior to August 30, 2016 and 50 percent disabling thereafter is remanded. Entitlement to service connection for a thoracolumbar disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1987 to April 1988, and from February 2003 to November 2003. The issues on appeal arise from the Veteran’s February 22, 2012, claim. The Board notes that a July 2020 rating decision from the Agency of Original Jurisdiction (AOJ) granted a rating of 50 percent disabling for migraines effective October 3, 2019. The Board notes that a 50 percent rating is the highest possible rating for migraines under DC 8100. That rating decision represents a complete grant for migraines from October 3, 2019. However, as addressed in the REMAND below, the noncompensable rating for migraines from February 22, 2012, to October 2, 2019, remains on appeal. 1. Entitlement to an initial rating in excess of 10 percent disabled for GERD The Board remanded this claim, in part, to obtain opinion as to whether the Veteran’s GERD symptoms are productive of considerable impairment of health. The October 2019 VA examination report did not specifically address this question. As such, the claim must be remanded for an addendum opinion. 2. Entitlement to a higher rating for migraine headaches evaluated as noncompensable prior to August 30, 2016 and 50 percent disabling thereafter. The Veteran has appealed the initial rating assigned for migraine headaches originally rated as noncompensable effective February 22, 2012. Following a Board remand, the AOJ awarded a 50 percent rating effective October 3, 2019. The AOJ indicated that this was deemed a “TOTAL GRANT” of benefits sought on appeal, and did not address the evidence further in a supplemental statement of the case. However, the appeal period extends to February 22, 2012 and the Veteran is presumed to seek the maximum benefits for the entire appeal period. See AB v. Brown, 6 Vet. App. 35 (1993). The Board must remand this issue for compliance with 38 C.F.R. § 19.38. 2. Entitlement to service connection for a thoracolumbar disorder is remanded. The claims file contains conflicting medical opinions regarding the nature and etiology of the Veteran’s thoracolumbar spine disorder. A remand is needed to obtain an additional medical opinion adequate for rating purposes. The claims file contains the following conflicting medical opinions regarding the Veteran’s thoracolumbar spine disorder: • a September 2013 private medical opinion indicating that the Veteran’s thoracolumbar spine disorder is at least as likely as not related to in-service activity, including carrying heavy munitions boxes; • a January 2014 VA examination indicating that the lumbar disc bulge is less likely than not related to service because the symptoms appeared after service and no complaints were noted during service; • an October 2019 VA examination diagnosing the Veteran with lumbar strain and lumbar spondylosis and containing the opinion that the Veteran’s the symptoms associated with this diagnosis are at least as likely as not related to service, but containing inadequate rationale for rating purposes; and • a June 2020 VA examination indicating the Veteran’s thoracolumbar disorder predated his current service and dated back to 2007. (The Board notes, however, that the examiner’s opinion applies an incorrect standard as the claim of entitlement to service connection is based on the Veteran’s periods of service prior to 2007.) The matters are REMANDED for the following action: 1. Obtain VA treatment records since March 2020 and associate them with the claims file. 2. Obtain an addendum opinion as to whether the Veteran’s GERD symptoms are productive of considerable impairment of health. In so doing, the examiner should discuss any health complications caused by GERD to include whether his B-12 supplements are attributable to a health complication of GERD. 3. Forward the claims folder to a qualified examiner for an addendum opinion regarding the nature and etiology of the Veteran’s thoracolumbar spine disorder. The examiner should opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater possibility) that any diagnosed thoracolumbar spine disorder had its onset during active duty, or is otherwise etiologically related to his active duty service. The examiner should address the following: • October 2003 post deployment questionnaire reflecting that the Veteran noted experiencing no symptoms of back pain and noted no medical problems; • September 2007 private medical records containing imaging that reflects a mild posterior disc bulge and mild spondylosis; • September 2013 private medical opinion indicating that the Veteran’s thoracolumbar spine disorder is at least as likely as not related to in-service activity, including carrying heavy munitions boxes; • January 2014 VA examination indicating that the lumbar disc bulge is less likely than not related to service because the symptoms appeared after service and no complaints were noted during service; • October 2019 VA examination diagnosing the Veteran with lumbar strain and lumbar spondylosis and containing the opinion that the Veteran’s the symptoms associated with this diagnosis are at least as likely as not related to service, but containing inadequate rationale for rating purposes. If an examination is needed, one should be scheduled. All opinions expressed must be supported by complete rationale. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Howell, 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.