Citation Nr: 21006399 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 16-11 934 DATE: February 4, 2021 REMANDED Entitlement to service connection for gastrointestinal problems, specifically gastroesophageal reflux disease (GERD), as secondary to low back disability, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Marine Corps from July 1972 to January 1973. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This claim was previously before the Board in April 2019 when the Board denied the claim. The Veteran appealed the Board’s April 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2020 Order, the Court granted a Joint Motion for Partial Remand (JMR) vacating the Board’s April 2019 decision and remanded the matter for action consistent with the terms of the joint motion. Thereafter, the Veteran’s claim was remanded by the Board in September 2020 for further development consistent with the Court’s decision. Entitlement to service connection for gastrointestinal problems, specifically GERD, as secondary to low back disability, is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Following the September 2020 Board remand, a VA examiner opined in a November 2020 opinion that the Veteran’s GERD was less likely than not proximately due to or the result of the Veteran’s service-connected lumbar spine disability. In support of the opinion, the VA examiner reasoned that there is significant medical literature regarding nonsteroidal anti-inflammatory drugs (NSAIDs) and gastric ulcers but only predominantly theoretically and correlating evidence regarding GERD. Furthermore, the VA examiner reasoned that the medical literature reflects that NSAIDs do not have an effect on lower esophagus sphincter and “typically” do not cause GERD. The VA examiner then concluded that given there is no medical literature in support of causality, no nexus is reasonable. Initially, the Board notes that the reasoning in support of the opinion is speculative as the VA examiner noted that NSAIDs “typically” do not cause GERD. In addition, the Veteran submitted medical literature in July 2020 in support of a positive causal relationship between NSAIDs and GERD. Thus, the VA examiner’s conclusion that no medical literature supports causality does not accurately reflect the evidence of record. As such, an additional VA opinion is necessary. In addition, the VA examiner opined that the Veteran’s GERD was less likely than not aggravated beyond its natural progression by the Veteran’s service-connected lumbar spine disability. As part of the rationale in support of the opinion, the VA examiner noted that “there is observed AGGRAVATION of an existing condition of GERD with the frequent use of NSAIDs.” However, the VA examiner did not explain as part of the rationale as to whether the aggravation noted in the rationale in support of the opinion was beyond the natural progression of the Veteran’s GERD. As such, an additional VA opinion is necessary. The matter is REMANDED for the following action: 1. Obtain updated VA treatment records from November 2020 to the present. 2. Obtain an addendum opinion from the November 2020 VA examiner, if available, or another appropriate medical professional if the November 2020 VA examiner is not available, regarding the Veteran’s GERD. The electronic claims file must be made available to the VA examiner for review in connection with the request for an opinion. If the VA examiner determines that an in-person examination (including via telehealth interview) is needed in order to answer the questions posed, then such should be scheduled. After reviewing the claims file, the VA examiner should address the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s GERD is caused by his service-connected low back disability, to include the NSAIDs taken for his low back disability? In addressing this question, the VA examiner is asked to address the medical literature submitted by the Veteran’s representative in July 2020 titled “Is Medication Causing Your Heartburn?” (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s GERD is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected low back disability, to include the NSAIDs taken for his low back disability? If the Veteran’s GERD has been aggravated by his service-connected low back disability, the VA examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In addressing this question, the VA examiner is asked to address the medical literature submitted by the Veteran’s representative in July 2020 titled “Is Medication Causing Your Heartburn?” A complete rationale for any opinion must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. K. MARENNA Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Breitbach, 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.