Citation Nr: 21007570 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 10-05 882 DATE: February 10, 2021 REMANDED Service connection for gastroesophageal reflux disease (GERD)/hiatal hernia is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1966 to January 1988. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2009 rating decision by the Department of Veterans Affairs (VA). This case was remanded in April 2015, June 2017, January 2019, and August 2020 for further development; it has since been re-assigned to the undersigned. Unfortunately, the Board finds a remand is required to correct deficiencies in the October 2020 VA examination report. The Board finds that the October 2020 VA examiner’s opinion did not respond to the previous remand directives, which required that a rationale must be provided for any opinion expressed. The August 2020 remand order requested that the VA examiner opine whether the Veteran’s GERD is related to active service or any incident of service, including due to conceded herbicide agent exposure. The examiner was advised that the Veteran reported experiencing acid reflux, heartburn, burping, and regurgitation while in active service. The examiner opined that there is no causal relationship between GERD and service or by presumption to herbicide. He provided no further explanation or analysis. The examiner acknowledged that the Veteran reported acid reflux, heartburn, burping, and regurgitation while in active service, and stated “this examiner can opine that the information provided by the Veteran is not supported by medical evidence.” He later stated that many reported symptoms during service by the Veteran may be misunderstood as GERD, but not GERD. He stated that GERD is a specific entity, and distinctly independent of minor gastrointestinal complaints that masquerade as GERD, but resolve, as not casually related to GERD. However, the examiner did not provide any explanation or analysis as to why the Veteran’s reported in-service symptoms were not medically related to GERD. Further, the Veteran is competent to report in-service and post-service symptoms he experiences. The examiner opined that there is no causal relationship between GERD and PTSD, and that the Veteran’s GERD is due to obesity and age. However, the examiner again did not provide any explanation or analysis to explain his opinion finding no causal relationship. The remand order requested that the examiner not review or rely upon VA medical opinions dated in October 2018, December 2019, and in May 2020 in preparing his or her own opinion. In response, the examiner stated that previous opinions are also from physicians who have quoted and relied on credible authoritative medical literature and evidence. In addition to the Stegall issue discussed above, the Board finds that remand is also appropriate to obtain an addendum opinion concerning whether obesity is an “intermediate step” between the service-connected PTSD with alcohol use disorder and the diagnosed GERD. The Board notes that obesity is not a disability for purposes of VA benefits; hence, it cannot be service connected on a direct basis. See Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). However, indirect secondary service connection can be granted with obesity acting as an “intermediate step.” See VAOPGCPREC 1-2017 (Jan. 6, 2017). Specifically, a grant is warranted (1) if the service-connected disability caused the Veteran to become obese, (2) if obesity was a substantial factor in causing a subsequent disability, and (3) if the subsequent disability would not have occurred but for obesity. Id. The VA examination contains the examiner’s conclusion that obesity is a cause of the Veteran’s GERD. In a November 2020 statement, the Veteran’s representative requested additional medical assessment on whether the Veteran’s obesity is due to his service-connected PTSD. The statement references an article titled Post-Traumatic Stress Disorder Predicts Future Weight Change in the Millennium Cohort Study, concluding that “PTSD is independently associated with a higher risk of weight gain and loss, the former of which leads toa higher prevalence of overweight and obesity and a higher risk of comorbidities associated with excessive body adiposity.” The statement also references an article titled Stress- and PTSD-associated obesity and metabolic dysfunction: A growing problem requiring further research and novel treatments, concluding “PTSD has emerged as predictor of obesity and metabolic dysfunction in more recent years” in both “general and veteran populations.” On remand, an addendum opinion is required to help inform the Board’s decision on whether obesity is an intermediate step between the Veteran’s service-connected PTSD and his currently diagnosed GERD. The matters are REMANDED for the following action: 1. The AOJ should obtain updated VA and non-VA treatment records. 2. After the above development is completed, the AOJ should obtain an addendum opinion, from an appropriate clinician, to determine the nature and etiology of the Veteran’s GERD. This opinion should be provided by a clinician other than the clinicians who provided the prior opinions dated in October 2018, December 2019, May 2020, and October 2020. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: a) Is it at least as likely as not (50 percent or greater probability) that the disability was either incurred in or otherwise related to the Veteran’s active duty service? Please explain why. The Veteran’s competent reports of experiencing acid reflux, heartburn, burping, and regurgitation while in active service must be considered and discussed. b) Is it at least as likely as not (50 percent or greater probability) that the disability was either incurred in or otherwise related to the Veteran’s conceded exposure to herbicide agents in Vietnam? Please explain why. The examiner may not solely rely on an absence of a VA presumption for a diagnosed disability and must discuss the Veteran’s specific background. c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s GERD/hiatal hernia disability was caused by the Veteran’s service-connected PTSD with alcohol use disorder? Please explain why. d) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s GERD/hiatal hernia disability was aggravated by the Veteran’s service-connected PTSD with alcohol use disorder? Please explain why. The opinion must address whether the disability increased in severity (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. e) Is the Veteran’s obesity an “intermediate step” between the service-connected PTSD with alcohol use disorder and the currently diagnosed GERD/hiatal hernia? The examiner should address the October 2020 VA examiner’s finding that the Veteran’s GERD is related to obesity, as well as the information provided by the Veteran’s November 2020 statement including the articles titled Post-Traumatic Stress Disorder Predicts Future Weight Change in the Millennium Cohort Study, and Stress- and PTSD-associated obesity and metabolic dysfunction: A growing problem requiring further research and novel treatments. In rendering the requested opinions, the examiner must consider all relevant evidence of record. A complete and thorough rationale must be provided for all opinions. If the examiner is unable to offer the opinions requested, he or she must explain in detail why that is the case. The clinician finally is advised not to review or rely upon VA medical opinions dated in October 2018, December 2019, and in May 2020 in preparing his or her own opinion. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Kerner, 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.