Citation Nr: 21016076
Decision Date: 03/19/21	Archive Date: 03/19/21

DOCKET NO. 16-28 323
DATE: March 19, 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 May 2003 to February 2007.

This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA).

The Veteran presented testimony at a Board hearing in July 2019.  Unfortunately, a transcript of the hearing is not available for review due to a malfunction with the Digital Audio Recording System during the hearing.  The Veteran was informed of the malfunction in a letter dated July 23, 2020, and was afforded an opportunity to request another Board hearing.  (7/23/2020, Hearing Related, p. 1).  He did not respond to the letter.  The Board therefore assumes that he does not desire another hearing and will proceed accordingly. 

Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease (GERD) 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.  In this regard, no VA examiner has opined on whether the Veteran’s GERD symptoms are productive of considerable or severe impairment of health as contemplated by 38 C.F.R. § 4.114, Diagnostic Code 7346. 

In rendering this decision, the Board acknowledges that the Veteran was afforded a VA examination in September 2015.  At the time of the examination, the Veteran’s symptoms included persistent recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, sleep disturbances caused by esophageal reflux, nausea, and vomiting.  The examiner did not opine on whether the Veteran’s symptoms are productive of considerable or severe impairment of health.  (9/15/2015, C&P Exam, p. 2-3). 

The Veteran also submitted an esophageal conditions disability benefits questionnaire completed by his private medical provider dated in July 2019.  The private examiner indicated that the Veteran’s symptoms included persistent recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal arm or shoulder pain, sleep disturbances caused by esophageal reflux, and nausea. As with the VA examination, the private examiner did not opine on whether the Veteran’s symptoms are productive of considerable or severe impairment of health.  (7/15/2019, BVA-General, p. 2-3). 

Upon remand, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of GERD.  The examiner should specifically opine on whether the Veteran’s symptoms are productive of considerable or severe impairment of health.

Additionally, the Board notes that the most recent VA medical records associated with the Veteran’s claims file are dated in April 2015.  Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal.  A remand is required to allow VA to obtain them.

The matters are REMANDED for the following action:

1. The AOJ should obtain copies of VA treatment records for the Veteran’s disabilities from April 2015 to the present.

2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected GERD.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the  disability under the rating criteria.  The examiner should specifically opine on whether the Veteran’s symptoms are productive of considerable or severe impairment of health.   

 

 

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.