Citation Nr: 21005991 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 09-37 983 DATE: February 3, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disorder (GERD) and hiatal hernia, to include as secondary to medications for service-connected disabilities, is remanded REASONS FOR REMAND The Veteran served on active duty from June 1971 to June 1991. This case comes before the Board of Veterans’ Appeals (Board) on appeal of an April 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in September 2011. The United States Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Partial Remand (Joint Motion) in September 2019 and vacated the December 2018 Board decision, returning the case to the Board. In the aforementioned Joint Motion, the parties determined that VA erred when it failed to obtain a clarifying opinion and when it failed to obtain outstanding relevant medical records under VA’s duty to assist. Specifically, in November 2012, the Veteran authorized VA to obtain private medical records relevant to his claim, and VA has failed to obtain such records despite the Veteran’s authorization to do so. The Joint Motion parties further agreed that the May 2017 examination opinion was inadequate because the examiner did not address whether the Veteran’s prescribed medications used to treat his service-connected disabilities aggravate his GERD and hiatal hernia. In December 2019, the Board remanded the case pursuant to the September 2019 Joint Motion. The Veteran was afforded a VA examination and opinion in June 2020. In the June 2020 opinion, the examiner opined that there is no medical evidence to support a causal link or proven aggravation by the Veteran’s medications. The examiner cited a medical article from “uptodate.com” that listed “several drugs” that can cause reflux esophagitis. Celebrex was not on the list of the “several drugs.” In addition, the examiner found no credible evidence to support a causal link between hiatal hernia with GERD and the Veteran’s service-connected disabilities. The RO requested an addendum opinion to the June 2020 examination. The RO found that there was a lack of any case-specific analysis of the evidence, to include a discussion of what the May 2017 examiner said about Nexium, Celebrex, and GERD. The RO also stated that the June 2020 examination did not cite to any medical treatises to support the conclusion and that a review of “drugs.com” portrays GERD as a common side effect of Celebrex. In the August 2020 addendum opinion, the examiner essentially reiterated the June 2020 opinion and added that the May 2017 opinion was not valid due to the lack of support by credible peer-reviewed literature. The examiner also added that the prior stomach opinion from December 2010 was reviewed and non-contributory, and the esophagus DBQ from March 2009 was reviewed and did not change her medical opinion. The Board finds that the single citation from “uptodate.com” regarding medication used in the June 2020 and August 2020 opinions does not constitute an adequate rationale to find that Celebrex could not and/or did not cause or aggravate the Veteran’s GERD or hiatal hernia. The examiner also failed to cite any medical treatises to support her conclusion in the addendum opinion, as requested by the RO. In addition, the June 2020 and August 2020 opinions make no mention of Nexium and how the Veteran has been prescribed the medication to control symptoms of GERD. The Board finds that the VA opinions from June 2020 and August 2020 lack an adequate rationale. Thus, a new VA addendum opinion is warranted. Lastly, the Joint Remand instructed the Board to obtain the Veteran’s recent private treatment records that were not in the file at the time of the decision. In November 2019, the Veteran submitted a Waiver of Opportunity to Submit Additional Evidence and indicated that he did not have additional evidence or argument to submit. In conjunction with this remand, the Board finds another attempt to obtain recent medical records would nevertheless be helpful, given the locations of treatment provided. The matter is REMANDED for the following action: 1. Make another attempt to obtain any and all relevant private medical records (e.g., Dr. Williams; Family Healing Healthcare Clinic and Lincoln Trail Medical Associates) and VA medical records and associate such records with the claims file. If such records are unavailable, this must be noted in a formal finding. 2. Return the claims file to a medical professional with appropriate expertise, preferably other than the June 2020 examiner, for a new VA addendum opinion (or examination, if deemed necessary). The claims file, including all VA examinations/opinions, all Board remands, and the Joint Motion, must be made available to, and reviewed by, the examiner. The addendum opinion must indicate that the claims file was reviewed in its entirety. Following a review of the entire claims file, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s GERD and hiatal hernia disabilities are proximately due to or aggravated by the Veteran’s service-connected disabilities, to include the medications taken for such disabilities (particularly Celebrex and Nexium as indicated). Please cite to clearly notated medical treatises, as appropriate. The VA examiner should refer to the February 2016 Rating Decision codesheet for the most current list of the Veteran’s service-connected disabilities. If aggravation is found, a baseline for the level of disability of the GERD and hiatal hernia absent aggravation must be established, if possible. The examiner’s rationale must include a detailed discussion of the effects or aggravation by the Veteran’s medications, if any, on his GERD and hiatal hernia (particularly Celebrex and Nexium as indicated). The examiner must further discuss the Veteran’s lay statements and all pertinent evidence. If the examiner discounts those statements, an explanation must be provided. All opinions must be supported by a detailed and complete rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hetman 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.