Citation Nr: 21014029 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 17-35 478 DATE: March 11, 2021 ORDER New and material evidence having been received, the petition to reopen the claim of entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for Crohn’s disease is remanded. Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. A July 2013 rating decision denied service connection for GERD. A subsequent February 2014 rating decision once again denied service connection for GERD. The Veteran did not appeal these decisions, and new and material evidence was not received within a year of their issuance. 2. Since the February 2014 rating decision, the Veteran has submitted additional evidence that raises a reasonable possibility of substantiating his claim for entitlement to service connection for GERD. CONCLUSIONS OF LAW 1. The February 2014 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 20.302, 20.1103.  2. The evidence received since the February 2014 rating decision is new and material. Therefore, the criteria to reopen the claim of service connection for GERD is met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156.  REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1984 to February 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions in December 2016 and September 2018 by the Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran presented testimony at a Board hearing in September 2020. A transcript of the hearing is associated with the Veteran’s claims folder. 1. New and material evidence having been received, the petition to reopen the claim of entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. Applicable law provides that a final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. The credibility of the evidence is presumed in determining whether new and material evidence has been submitted. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. The issue of entitlement to service connection for GERD was last denied in a February 2014 rating decision on the basis that the medical evidence of record did not demonstrate a medical link between the Veteran’s current medical disability and his military service. The Veteran did not appeal the February 2014 rating decision and no new and material evidence was received within a year of the decision. Since that time, the Veteran was afforded a Board hearing in September 2020. During the Board hearing, the Veteran testified that he has been taking ranitidine since service. (9/10/2020, Hearing Transcript, p. 6). This evidence is “new,” because it was not submitted to the AOJ prior to the February 2014 rating decision, and the evidence is “material,” because it speaks to continuity, and thus relates to the unestablished element of whether the Veteran’s GERD is related to service. As such, the claim of entitlement to service connection for GERD is reopened. REASONS FOR REMAND 1. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. 2. Entitlement to service connection for Crohn’s disease is remanded. Upon review of the claims file, the Board has determined that further development is necessary before the claim can be adjudicated.  38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA opinions was issued with respect to GERD and Crohn’s disease in June 2020. Regarding GERD, the VA examiner opined that GERD was less likely than not incurred in or caused by service. The examiner indicated that the Veteran’s symptoms “are more likely related to lifestyle choices as well as medications versus any environmental exposures.” (6/9/2020, C&P Exam, p. 3). Regarding Crohn’s, the VA examiner opined that the disorder was less likely than not incurred in or caused by service. The examiner indicated that medical literature does not support a link between environmental contaminations and Crohn’s disease. (6/9/2020, C&P Exam, p. 3). The Board finds that the June 2020 opinions are inadequate for evaluation purposes. While the examiner did proffer opinions regarding whether the Veteran’s disabilities are related to environmental contaminations, the examiner did not opine on whether the Veteran’s disabilities are otherwise related to service. Upon remand, a VA examiner should opine whether the Veteran’s GERD and Crohn’s disease are related to his active duty service. Specifically, the examiner should consider a January 1986 in-service complaint of left upper quadrant pain with bloody stools. (11/5/2012, STR - Medical, p. 77). In rendering this decision, the Board acknowledges a June 2013 VA opinion in which a VA examiner opined that the Veteran’s GERD is not related to service. The June 2013 examiner noted the Veteran’s complaints of left upper quadrant pain, but found that the complaints were related to a diagnosis of costochondritis. (6/3/2013, VA Examination, p. 7). The Board further finds that the June 2013 opinion is inadequate, as it is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In this regard, while the Veteran was diagnosed with costochondritis on January 10, 1986, he returned to sick call on January 26, 1986, with complaints of left upper quadrant pain and bloody stools. The June 2013 examiner did not acknowledge the January 26, 1986, complaints. The opinion is therefore inadequate for evaluation purposes. Based on the aforementioned, the Board finds that the claims must be remanded for further medical development. 3. Entitlement to service connection for hypertension is remanded. Upon review of the claims file, the Board has determined that further development is necessary before the claim can be adjudicated.  38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran was afforded a VA opinion for hypertension in June 2020, wherein a VA examiner opined that hypertension was less likely than not related to service. In rendering her decision, the examiner noted that the Veteran was diagnosed with hypertension well after active service. (6/9/2020, C&P Exam, p. 3). The Board finds that the June 2020 opinion is inadequate for evaluation purposes. While the examiner did proffer an opinion regarding whether the Veteran’s hypertension was related to environmental contaminations, the examiner did not opine on whether hypertension is otherwise related to service. Upon remand, a VA examiner should opine whether the Veteran’s hypertension was incurred during the Veteran’s active service. In doing so, the examiner should acknowledge the Veteran’s blood pressure reading of 142/82 during his separation examination. See Understanding Blood Pressure Readings, American Heart Association, last visited March 3, 2021, http://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings; (11/5/2012, STR - Medical, p. 6). Based on the aforementioned, the Board finds that the claim must be remanded for further medical development. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records for the Veteran’s disabilities from March 2020 to the present. 2. Schedule the Veteran for a VA examination for GERD. The examiner must review the claims file. The examiner is asked to opine whether GERD is at least as likely as not related to service. In rendering an opinion, the examiner must address a January 1986 in-service complaint of left upper quadrant pain with bloody stools. (11/5/2012, STR - Medical, p. 77). The examiner must provide a rationale to support the opinion. 3. Schedule the Veteran for a VA examination for Crohn’s disease. The examiner must review the claims file. The examiner is asked to opine whether Crohn’s disease is at least as likely as not related to service. In rendering an opinion, the examiner must address a January 1986 in-service complaint of left upper quadrant pain with bloody stools. (11/5/2012, STR - Medical, p. 77). The examiner must provide a rationale to support the opinion. 4. Schedule the Veteran for a VA examination for hypertension. The examiner must review the claims file. The examiner is asked to opine whether hypertension is at least as likely as not related to service. In rendering an opinion, the examiner must address the Veteran’s separation examination blood pressure reading of 142/82. (11/5/2012, STR - Medical, p. 6). The examiner must provide a rationale to support the opinion. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Glenn, 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.