Citation Nr: 21007201 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 14-42 598 DATE: February 9, 2021 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to undiagnosed illness, and/or secondary to medications prescribed for service-connected disabilities, is denied. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia theater of operations during the Persian Gulf War. 2. The most probative evidence of record does not establish that it is at least as likely as not that the Veteran’s diagnosed GERD manifested in service or is otherwise etiologically related to service. 3. The most probative evidence of record does not establish that it is at least as likely as not that the Veteran’s diagnosed GERD is proximately due to, or aggravated by, a service-connected disability, to include treatment therefor. CONCLUSION OF LAW The criteria for entitlement to service connection for GERD, to include as due to undiagnosed illness, and/or secondary to medications prescribed for service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(d), 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from November 1990 to February 2013. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board last remanded the issue on appeal in October 2018. Specifically, the Board requested any outstanding VA treatment records be associated with the claims file and an addendum medical opinion. A review of the record shows substantial compliance with the Board’s remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The case has been returned to the Board for review. The Board notes that the issue of entitlement to service connection for a liver condition, to include as due to an undiagnosed illness and/or medication taken for service-connected PTSD and a back condition was denied in the October 2018 Board decision. Board decisions are final when issued. See 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. Accordingly, the issue is no longer before the Board. On the Veteran’s December 2014 substantive appeal, he requested a videoconference hearing. However, in October 2017, the Veteran requested to withdraw his hearing request. See October 2017 report of general information. Therefore, the Veteran’s hearing request is withdrawn, and the Board will proceed with adjudication of the issue. See 38 C.F.R. § 20.704(e). Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to undiagnosed illness, and/or secondary to medications prescribed for service-connected disabilities. The Veteran seeks service connection for GERD. See October 2012 Statement in Support of Claim. Specifically, the Veteran asserts that his GERD is a result of his service in the Gulf War. See July 2013 Notice of Disagreement (NOD). The Veteran also asserts that his GERD is secondary to the medication he takes for his service-connected disabilities. See December 2014 VA Form 9; November 2020 Appellate Brief; September 2018 Appellate Brief. Service connection may be granted if there is a disability resulting from personal injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or aggravated beyond natural progression by a service-connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection may be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, including resulting from undiagnosed illness, that became manifest during active duty or became manifest to a compensable degree within a prescribed presumptive period, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Laypersons are competent to report objective signs of illness. Id. A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as: (1) Chronic fatigue syndrome; (2) Fibromyalgia: and (3) Functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Compensation under 38 U.S.C. § 1117 shall not be paid if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran’s most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran’s own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term “Persian Gulf veteran” means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Persian Gulf War is defined as beginning on August 2, 1990, through a date to be prescribed by Presidential proclamation or law. 38 U.S.C. § 101(33); 38 C.F.R. § 3.2(i). Direct incurrence service connection As noted, the Veteran seeks service connection for GERD that he contends is due to his active service in the Persian Gulf War, to include as due to an undiagnosed illness. The evidence of record demonstrates the Veteran is currently diagnosed with GERD. See September 2014 VA examination. Therefore, the first element of service connection has been met. See Shedden, 381 F.3d at 1167. Regarding service connection of a presumptive basis, the Veteran’s DD 214 indicates service in Southwest Asia from January 1991 to August 1991. Therefore, he is a Persian Gulf veteran for these purposes. In a September 2014 VA examination, the VA examiner confirmed the Veteran has a current diagnosis of GERD. See September 2014 VA examination. In a September 2014 Gulf War examination, the VA examiner concluded that GERD is a distinct disease with clear and specific etiologies and diagnosis. The VA examiner further explained that GERD has not been associated with the illnesses or exposures described in veterans returning from the Gulf War and in medical research published in peer-reviewed medical journals. See September 2014 Gulf War examination. Thus, the VA examiner concluded that the Veteran’s GERD was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. Id. Therefore, the record does not support a finding that the Veteran’s GERD is due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness. See 38 U.S.C. § 1117; 38 C.F.R. § 3.3137(a)(1). Accordingly, the preponderance of the evidence is against finding that the Veteran is entitled to presumptive direct-incurrence service connection for an undiagnosed gastrointestinal illness. The presumptive regulations, however, do not preclude a claimant from establishing service connection with proof of direct causation. 38 U.S.C. § 1113(b); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). As noted, the Veteran is currently diagnosed with GERD satisfying the criteria for the first element of service connection. As to the second element of service connection, event or injury in service, the Veteran’s service treatment records (STRs) show complaints of stomach pains. See March 1992 and January 1993 STRs. In March 1992, the Veteran was assessed with chronic stomach pain. See March 1992 STRs. In January 1993, the Veteran complained of diarrhea, vomiting, and stomach pain and was assessed with possible gastritis. See January 1993 STRs. Therefore, the second element of service connection has been met. See Shedden, 381 F.3d at 1167. The remaining question for the Board is whether there is a link between the Veteran’s currently diagnosed GERD and his active service. In that regard, the Veteran was initially afforded a VA examination in September 2014. At the September 2014 VA examination, the Veteran reported he had epigastric pain, and reflux with regurgitation beginning in approximately 2012. See September 2014 VA examination. The VA examiner noted the Veteran was referred to GI and diagnosed with GERD in August 2012. Id. However, the VA examiner did not opine as to whether the Veteran’s GERD was etiologically related to his active duty service. In a March 2016 VA examination, the VA examiner only addressed secondary service connection as discussed below. As noted, the Board remanded the issue in October 2018. On remand, the Veteran was afforded a VA addendum medical opinion in October 2019. The VA examiner opined that the Veteran’s GERD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. See October 2019 VA examination. The VA examiner noted review of the Veteran’s complaints of diarrhea, vomiting, and stomach pain in service and that the Veteran was diagnosed with viral gastroenteritis in service. Id. The VA examiner explained that the viral gastroenteritis is an acute self-limiting condition and that there was no evidence in which there were complaints consistent with GERD in service. Id. The VA examiner further noted the Veteran reported that his symptoms were first present in 2012 at the September 2014 VA examination, 19 years after active service, and that he was officially diagnosed with GERD in August 2012. Id. Thus, the VA examiner concluded that the evidence of record in the STRs and self-report of onset of symptomatology does not a support a link between the Veteran’s GERD and active military service. Id. To the extent that the Veteran asserts that his GERD is related to his active service, the Board notes that he has not been shown to have the medical training necessary to be deemed competent to provide an opinion as to the etiology of his GERD diagnosis. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). This is because the etiology of a gastrointestinal disability is a complex medical matter requiring specialized medical training. Id. Moreover, there is no competent evidence contrary to the October 2019 VA medical opinion. The VA examiner noted review of the Veteran’s VA e-folder, STRs, and provided rationale for the medical opinion proffered. See October 2019 VA medical opinion. Therefore, the Board finds the October 2019 VA medical opinion adequate for decision making purposes and affords it significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). In sum, while there is a diagnosis of GERD, the preponderance of the evidence does not establish that the Veteran’s GERD was incurred in service or otherwise etiologically related to his active service, including due to service in Southwest Asia. Since the preponderance of the evidence is against the claim for service connection for GERD on a direct-incurrence basis, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Accordingly, entitlement to service connection for GERD on a direct-incurrence basis is denied. Secondary service connection The Veteran seeks service connection for GERD that he contends is secondary to medications prescribed for his service-connected disabilities. See December 2014 VA Form 9; November 2020 Appellate Brief; September 2018 Appellate Brief. The Board finds that secondary service connection is not warranted. The threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence that the disability for which service connection is sought is proximately due to, or aggravated beyond natural progression by, the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). As noted, the Veteran is currently diagnosed with GERD. The record demonstrates the Veteran is service-connected for posttraumatic distress disorder (PTSD), thoracic spondylosis with intervertebral disc syndrome with associated erectile dysfunction, voiding dysfunction, and lower extremity radiculopathy, and irritable bowel syndrome. Therefore, the first and second criteria for secondary service connection have been met. See Wallin, 11 Vet. App. at 512. In regard to the third element of secondary service connection, the Board finds there is no competent evidence that the Veteran’s GERD is proximately due, or aggravated, by his service-connected disabilities. The Veteran’s VA treatment records do not contain any indication the Veteran’s GERD was caused by or aggravated by service-connected disabilities, to include treatment therefor. The Veteran was afforded a VA examination in March 2016. The VA examiner opined that the Veteran’s GERD was less likely than not proximately due, or the result of service-connected disabilities, and/or worsened by treatment for a service-connected disability. See March 2016 VA examination. The VA examiner explained that GERD is caused by lowering of pressure in the lower esophageal sphincter due to obesity, lying in a supine position, and laxity of the sphincter. Id. The VA examiner noted that though meloxicam has the potential of irritating the stomach lining, it does not cause GERD and it was less likely any medication listed in the Veteran’s active medication profile indicates GERD was caused by or actually worsened by taking the medication as prescribed for a service-connected disability. Id. The VA examiner noted review of the Veteran’s medical records and medical literature in concluding the Veteran’s GERD is less likely than not caused by and/or worsened by treatment for his service-connected disabilities. Id. As such, the Board finds the March 2016 VA medical opinion adequate and assigns it significant probative value. See Nieves-Rodriguez, 22 Vet. App. at 302. The Veteran’s representative contends that an October 2019 VA examination is inadequate because it did not address the Veteran’s claim to service connection for GERD secondary to prescribed medications for service-connected disabilities. See November 2020 Appellate Brief. However, the Veteran’s contentions were addressed in the March 2016 VA medical opinion in which the Board finds adequate for decision making purposes. Additionally, the Board previously determined the March 2016 VA medical opinion adequate when it remanded the issue for an addendum opinion to address direct-incurrence service connection only. See October 2018 Board decision. Moreover, the Veteran, nor his representative, have provided any competent evidence to the contrary to support his claim. The Board finds that the only evidence in favor of the Veteran’s claim is his own statement concerning his belief that his GERD is secondary to his service-connected disabilities, to include treatment therefor. The Board acknowledges that the Veteran is competent and credible to describe symptoms that he can perceive and describe. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he has not been shown to have the medical training or knowledge to be deemed competent to establish an etiological nexus between his diagnosed GERD and his service-connected disabilities, or aggravation by his service-connected disabilities, as such opinions require medical expertise and knowledge that he has not been shown to possess. See Kahana, 24 Vet. App. at 435. As such, the Board attaches more weight to the March 2016 VA examination than to the Veteran’s lay statements. In sum, the Board finds that, other than unsupported contentions, there is no competent evidence in the record of any etiological relationship between the Veteran’s GERD and his service-connected disabilities, to include treatment therefor. Thus, the criteria for service connection for GERD, to include as due to service-connected PTSD and back disability, including treatment therefor, have not been met. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Accordingly, the Veteran’s claim is denied. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).  Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. P. Moore, 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.