Citation Nr: 21008636 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 12-29 675 DATE: February 17, 2021 REMANDED Entitlement to an increased evaluation in excess of 30 percent for gastroesophageal reflux disease (GERD) is remanded REASONS FOR REMAND The Veteran served active duty in the United States Army from February 1996 to February 2006. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The claim was remanded in August 2016, September 2017, and May 2018 for further development. In the May 2018 remand, the RO was instructed to review and readjudicate the claim based on a May 2016 Disability Benefits Questionnaire (DBQ) from Dr. M.E.J. Following, while the claim was on appeal, the RO issued a rating decision in March 2019 that increased the Veteran’s evaluation for GERD to 30 percent effective July 27, 2010. In a July 2019 decision, the Board denied the increased evaluation claim in excess of 30 percent for GERD. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2020 Order, the Court granted a Joint Motion for Remand (Joint Motion) filed by the parties to vacate and remand the July 2019 Board decision. The case has since been returned to the Board for appellate review. In the Joint Motion, the parties agreed the Board provided an inadequate statement of reasons or bases for the denial of the higher evaluation. Specifically, the Board’s summarization of the VA examinations indicated that the Veteran had no incapacitating episodes of GERD and that the Veteran’s symptoms were not productive of severe impairment of health. However, it is noted that neither examiner made those statements. Thus, the claim was remanded back to the Board for an accurate discussion of the evidence. The Veteran is currently assigned a 30 percent evaluation for GERD, pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. The Board notes that the Veteran has also been diagnosed with ulcers, diverticulosis, and chronic gastritis which are not service connected. After a review of the claims file, it is clear that remand is necessary for additional development. Specifically, another VA examination to ascertain the current severity and manifestations of the Veteran’s GERD is needed. The Veteran was most recently evaluated during a VA examination in October 2017. The Board notes that the he was also afforded VA examinations related to his ulcers and diverticulitis on the same day. The findings are contained in separation examination reports. At that time, the examiner noted the Veteran’s GERD signs and symptoms include heartburn, substernal pain, and periodic vomiting more than four time per year. She also indicated the Veteran did not experience any material weight loss, nausea, melena with anemia, or hematemesis due to his GERD. She did not indicate that a combination of the symptoms produced severe impairment of health. However, the Board notes that the examiner did not address that the Veteran experienced reflux, nausea, epigastric distress, and sleep disturbance associated with his GERD. VA treatment records, May 2016 DBQ, and previous VA examination reports note this fact. Therefore, it is unclear if the examiner considered all of the Veteran’s current symptoms during the examination. Moreover, it appears there are outstanding treatment records that should be associated with the claims file. A review of the evidence shows that the last VA treatment records are from around August 2017. For these reasons, remand is necessary before adjudication of the claim. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for GERD. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records since August 2017 should also be obtained and associated with the claims file. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected GERD. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. The Board notes that the Veteran has been diagnosed with ulcers, diverticulosis, and chronic gastritis which are not service connected. The examiner should only address those symptoms related to GERD in the VA examination report. If no differentiation can be made, the examiner should state so and why. The examiner should report all signs and symptoms necessary for rating GERD. In particular, he or she should address whether there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptoms combinations productive of severe impairment of health. The examiner should also address the frequency and severity of each symptom. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.