Citation Nr: 21012530 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 17-18 544 DATE: March 4, 2021 ORDER Entitlement to gastroesophageal reflux disease (GERD) as secondary to posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. It is more likely than not that the Veteran had a current diagnosis of GERD at some point while his claim was pending. 2. The weight of the evidence of record is against a finding that the Veteran’s GERD is due to or worsened by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to GERD as secondary to PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the U.S. Army from February 1951 to January 1953, and in the U.S. Navy from August 1958 to August 1980. His Naval awards and decorations include the Combat Action Ribbon for service during the Viet Nam War. In a decision dated in February 2019 (02/21/2019 BVA Decision), the Board denied the appeal, and the Veteran appealed to the Court of Appeals for Veterans Claims (Court). While the appeal was pending, in December 2019, the Veteran, through his counsel, and the Secretary, VA, submitted a Joint Motion for Remand (JMR) wherein the parties asked the Court to vacate that part of the Board’s February 2019 decision that denied the GERD claim, and to remand the case to the Board for further review. See 01/15/2020 CAVC Decision, P. 1-8. In an Order dated in January 2020, the Court granted the JMR, vacated the February 2019 Board decision in part, and remanded the case to the Board for further review consistent with the JMR. In compliance with the Court’s Order, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for additional medical input. As discussed further below, the Board finds substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for GERD as secondary to PTSD is denied. Legal Requirements Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability that is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). In relevant part, 38 U.S.C. § 1154(a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); see also 38 C.F.R. § 3.102. Discussion In the February 2019 decision the Board determined that the weight of the medical evidence of record showed that the Veteran’s GERD was resolved by a surgical procedure, which meant that the Veteran did not have GERD at any time during or approximate to the pendency of the claim. See 02/21/2019 BVA Decision; see also Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The consensus of the parties in the JMR was that the Board did not fully explain its conclusion that VA fulfilled its duty to assist the Veteran. Specifically, the Board did not adequately explain its reasons for finding the November 2018 examination adequate in that the examiner did not reconcile his finding against a current diagnosis with the fact that the VA outpatient records continuously listed GERD in the Veteran’s Problem List. Additionally, August 2017 entries noted gastrointestinal (GI) bleeding, and proton pump inhibiters (PPI) were recommended. The JMR also stated that the AOJ had to ensure that all relevant non-VA treatment records from Lower Umpqua Hospital (LUH) have been obtained and are in the claims file. The Board also noted in its July 2020 remand that service connection is in effect for a duodenal ulcer, and that many of the outpatient record entries are related to that disease. Hence, a clinician needed to clarify what entries concern the Veteran’s ulcer and which address his GERD, and whether the two are related in any way, especially whether references to recent GI bleeding were related to both or one or the other. The AOJ asked the Veteran to provide the necessary releases so that VA could obtain the relevant records but had to return the forms because the Veteran did not sign them. See 08/21/2020 Subsequent Development Letter; 09/21/2020 Correspondence. The Veteran had informed the AOJ that his doctor had issued another prescription for a PPI. See 09/19/2020 Correspondence. The Board notes that while it does not appear that the Veteran returned the Forms 21-4142 signed, the medical examination report notes records from his non-VA provider. The AOJ arranged a medical review of the record as directed in the remand. The medical report (10/28/2020 C&P Exam) reflects that the clinician reviewed the Veteran’s records and opined that while the Veteran’s GERD symptoms resolved after his 2005 surgical procedure, later records showed a recurrence. Hence, the Veteran did in fact have a current diagnosis of GERD. Id. P. 2-3. Regarding the issue of service connection, the clinician opined that it was not at least as likely as not that the Veteran’s GERD is due to his PTSD or his ulcer disease. As concerns the latter, the clinician explained that ulcer disease and GERD are two separate GI conditions, and that ulcer disease does not cause GERD. The causes of GERD are primarily pathophysiologic, the clinician noted. The most common pathophysiologic mechanisms include mechanical issues with the lower esophageal sphincter and anatomical disruptions around the lower esophageal sphincter. GERD is separate from and not related to the prior ulcer disease, and the prior ulcer disease does not cause GERD. Id. P. 3. Regarding PTSD, the clinician noted that while there is evidence of an association between PTSD and GI conditions, including GERD and ulcer disease, that is not the same as a causal association. The medical literature does not support that PTSD causes GERD. The medical literature does not support that ulcer disease is a cause of GERD. Id. The examiner also opined that it is not at least as likely as not that either the Veteran’s PTSD or his ulcer disease worsens the GERD. The clinician noted that the Veteran’s show treatment of his GERD in 2020 with Omeprazole, but the records do not support a finding that either PTSD or ulcer disease contribute to the GERD symptoms. In fact, the Veteran’s records show that his ulcer disease is not active. Further, as noted earlier, ulcer disease is a different disease than GERD. Neither do the Veteran’s records support any involvement of his PTSD with his GERD. The examiner also addressed the records that document the Veteran’s diagnosis in August 2020 with Laryngopharyngeal (LPR) reflux), which is a condition that is separate from and a distinct entity from GERD, but it can produce symptoms similar to GERD. LPR can occur with or without GERD, and GERD can occur with or without LPR, and they are thought to have different anatomical mechanisms. The records support that the symptoms reported are also attributed to LPR per and August 2020 ENT evaluation. Hence, it cannot be concluded that there is a worsening of GERD, as the symptoms are likely due to both LPR and GERD. Further, the Veteran’s records support that the recurrence of the reported symptoms is more likely due to LPR than to GERD, and they do not support a finding that PTSD is contributory. The examiner then reemphasized that there currently is not active ulcer disease, so it does not worsen the GERD. Id. P. 4. The VA clinician reviewed the claims file, discussed the pathology of GERD, and provided a full rationale for his opinions based on medical studies and the Veteran’s medical records. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board notes that the clinician did not address the opinions of the non-VA nurse practitioner (NP) and physician see 10/20/2016 Medical Treatment-Non-Government Facility; 02/07/2017 Non-Government Facility. Nonetheless, the Board finds that this does not detract from the adequacy of the clinician’s review and opinion. Specifically, the NP’s and physician’s opinions addressed the causal relationship between the Veteran’s PTSD and his ulcer disease, not GERD. Their opinions led to the granting of service connection for the Veteran’s ulcer disease as due to his PTSD. See 12/18/2018 Rating Decision. Hence, the Board finds the VA clinician’s opinions highly probative and attaches significant weight to them. Thus, the Board finds that the claimed GERD is not proximately due to or aggravated by a service-connected disability. 38 C.F.R. §§ 3.310. Additionally, the record does not show, and the Veteran does not contend, that the claimed GERD symptoms are directly due to active service. Indeed, while a 2003 document notes a long history of GERD there is no showing of continuity of symptoms dating back to service and no medical opinion that otherwise links the current GERD to such service. In-service complaints including indigestive and constipation, assessed as a gaseous stomach, were noted in 1980 but a January 1981 UGI showed a normal esophagus. The November 2018 examiner found no nexus between the in-service complaints and the diagnosis of GERD eventually rendered in 2005; it is noted that the JMR did not find any deficiency with this aspect of the examination report. Moreover, as the opinion appears consistent with medical findings of record, including the 1981 diagnostic showing of a normal esophagus, it is deemed probative on this narrow aspect of the claim. Since the Board finds that the preponderance of the evidence is against the claim, there is no reasonable doubt to resolve. See Gilbert, 1 Vet. App. 49, 57-58; see also 38 C.F.R. § 3.102. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. T. Snyder 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.