Citation Nr: 21015502 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-10 491A DATE: March 17, 2021 REMANDED Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1975 to August 1979 with an honorable discharge. He also had service from April 1980 to July 1986 with a discharge under other than honorable conditions. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2013 decision of a Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in August 2018. A transcript of the hearing is of record. This matter was previously before the Board in March 2019 and September 2020 when it was remanded for further development. A November 2020 rating decision granted service connection for a lumbar spine disability. As the decision constitutes a full grant of the claim previously before the Board, the matter is no longer before the Board and will not be discussed further.   Entitlement to a rating in excess of 10 percent for GERD is remanded. Although the additional delay is regrettable, the Board finds further development is required before a decision can be made regarding the Veteran’s claim. In the September 2020 Board remand, the Board directed the Agency of Original Jurisdiction (AOJ) to schedule the Veteran for a VA examination to assess the current severity of his service-connected GERD. The Board asked the VA examiner to address a duodenal ulcer the Veteran reported had been diagnosed in March 2018. In the subsequent October 2020 VA examination, the examiner noted that there was no documented endoscopic evidence of a duodenal ulcer in the file. The examiner also stated that a February 2019 gastroenterology note did not diagnose a duodenal ulcer and that EGDs completed in March 2017 and May 2017 did not show a duodenal ulcer. Lastly, the examiner explained that an UGI completed in May 2017 also showed that the duodenum was normal. While there is no evidence of a duodenal ulcer in the record, an EGD completed by a private physician in March 2017 diagnosed a gastric ulcer. In addition, while an ulcer was not diagnosed in a May 2017 EGD, additional treatment records from May 2017 note a peptic ulcer. Therefore, the Board finds remand is required for an opinion regarding the nature and severity of the ulcers noted in the record. In addition, the Board notes that a July 2017 VA treatment record indicates that the Veteran’s gastric ulcer had healed but a January 2021 VA treatment record notes a gastric ulcer. Consequently, the Board finds it is unclear whether the Veteran currently has any gastric ulcers; thus, on remand, the examiner should provide an opinion on this issue. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records from January 2021 to the present. 2. Obtain an addendum opinion regarding the Veteran’s GERD. The Veteran’s claims file, including this remand, must be made available to the examiner for review. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinions. Following a review of the claims file, the examiner is asked to address the following: (a) Provide a retrospective opinion assessing the severity of the gastric and peptic ulcers noted in a March 2017 private treatment record and May 2017 VA treatment records. Specifically, the examiner is asked to report any signs and symptoms associated with the ulcers, to include completion of the appropriate Disability Benefits Questionnaire. (b) Provide a medical opinion as to whether the Veteran has a current diagnosis for an ulcer. If the examiner finds the Veteran does have a current diagnosis of an ulcer, he or she should report any signs and symptoms associated with the ulcer, to include completion of the appropriate Disability Benefits Questionnaire. In providing the opinion requested in (b), the examiner should address a July 2017 VA treatment record which indicates the Veteran’s gastric ulcer had healed, a February 2019 VA gastroenterology note that does not diagnose an ulcer, and a January 2021 VA treatment record which notes a gastric ulcer. A complete rationale for all opinions expressed must be provided. If the examiner cannot provide any requested opinion without resorting to speculation, he or she should   expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.