Citation Nr: 21006550 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 15-32 723 DATE: February 4, 2021 REMANDED Entitlement to a rating in excess of 30 percent for hiatal hernia with gastroesophageal reflux disease (GERD) and Barrett’s esophagus, status-post laparoscopic Nissen fundoplication and hiatal hernia repair is remanded. REASONS FOR REMAND The Veteran, who is the appellant in this case, served on active duty from December 1961 to May 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. By way of procedural background, this matter was previously before the Board in January 2019, at which time the Board awarded a 30 percent rating for the Veteran’s hiatal hernia with GERD and Barrett’s esophagus for the appellate periods prior to May 27, 2013 and from July 1, 2013 forward, and awarded a separate 10 percent rating from May 28, 2013 for a painful surgical scar associated with the Nissen fundoplication and hiatal hernia repair. As an aside, the Board notes that the Veteran is in receipt of a temporary total rating for post-surgical convalescence from May 28, 2013 to June 30, 2013. See September 2015 rating decision. In its January 2019 decision, the Board also remanded the issue of entitlement to a rating in excess of 30 percent for hiatal hernia with GERD and Barrett’s esophagus for additional development. The matter has now returned to the Board for further appellate consideration. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) and 38 U.S.C. § 7107(a)(2). 1. Entitlement to a rating in excess of 30 percent for hiatal hernia with GERD and Barrett’s esophagus is remanded. The Veteran asserts he is entitled to a rating in excess of 30 percent for his hiatal hernia with GERD and Barrett’s esophagus. The Board finds that the matter must be remanded for additional development. In June 2012, the Veteran presented to the Mayo Clinic hospital with complaints of vomiting blood and having black stools, and he was diagnosed with hematemesis and melena, the “most likely cause” of which the provider noted to be from the “upper gastrointestinal tract, specifically at the site of Barrett’s esophagus halo treatment.” See June 2012 private treatment record. In September 2012, the Veteran reported he was “recently told he is anemic and has been begun on iron” and that “he has recently been seen by his local physician due to feeling very tired, fatigued, and no energy. At that time he was found to be anemic and begun on iron.” See private treatment record dated September 18, 2012. Later in September 2012, the Veteran reported “ongoing issues with melanotic stools” since undergoing an upper endoscopy with radiofrequency ablation one week prior, and the provider noted “minimal anemia” on blood testing and that “likely the melanotic stools [were] probably more related to the iron” the Veteran was taking. See private treatment record dated September 24, 2012. The Board notes that symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health, would entitle the Veteran to a 60 percent rating under Diagnostic Code 7346. However, the February 2020 VA examiner did not address the symptoms of vomiting, hematemesis, melena, and anemia noted in the treatment records discussed above. Additionally, the February 2020 VA examiner did not provide a response as to the functional impact of the Veteran’s disability, which is relevant to the Board’s consideration of the extent of impairment of health caused by the Veteran’s symptoms. For these reasons, the Board finds the February 2020 VA examination incomplete, and these deficiencies must be remedied on remand. As an aside, during the October 2018 Board hearing, the Veteran testified that he was scheduled to undergo surgery in April 2019 related to his service-connected disability. Consequently, in its January 2019 Remand, the Board requested that the VA examiner “compare to the extent possible the symptoms and severity of disability, both prior to and after the surgery reportedly scheduled for April 2019.” VA and private treatment records do not reflect that the Veteran underwent surgery in April 2019; rather, on April 3, 2019, the Veteran had an upper gastrointestinal tract endoscopy with biopsies of his esophagus. As the Board’s only reason for the VA examiner to compare the Veteran’s symptoms was due to a reported surgery that did not occur, the Board finds that substantial compliance with this remand directive has been achieved. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the matter is REMANDED for the following action: 1. Obtain an addendum VA medical opinion regarding the nature and severity of the Veteran’s hiatal hernia with GERD and Barrett’s esophagus, preferably from the VA examiner who conducted the February 2020 VA examination, if possible. If this is not possible, the opinion should be rendered by another appropriate examiner. The claims file, including a copy of this Remand, must be made available to, and be reviewed by, the examiner. If another examination is indicated, one should be provided to the Veteran. After a review of the entire claims file, the examiner is asked to opine whether it is at least as likely as not (50 percent probability or greater) that any of the following are present (or were present during the period on appeal) due to the Veteran’s service-connected hiatal hernia with GERD and Barrett’s esophagus: i. Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; OR ii. Other symptom combinations productive of severe impairment of health * Specifically, address the following evidence: ** June 2012 private treatment record (Veteran presented to the Mayo Clinic hospital with complaints of vomiting blood and having black stools, and he was diagnosed with hematemesis and melena, the “most likely cause” of which the provider noted to be from the “upper gastrointestinal tract, specifically at the site of Barrett’s esophagus halo treatment.”). ** Private treatment record dated September 18, 2012 (Veteran reported he was “recently told he is anemic and has been begun on iron” and that “he has recently been seen by his local physician due to feeling very tired, fatigued, and no energy. At that time he was found to be anemic and begun on iron.”). ** Private treatment record dated September 24, 2012 (Veteran reported “ongoing issues with melanotic stools” since undergoing an upper endoscopy with radiofrequency ablation one week prior, and the provider noted “minimal anemia” on blood testing and that “likely the melanotic stools was probably more related to the iron” the Veteran was taking). 2. Then, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. M. Gill, 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.