Citation Nr: 21021455 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 19-23 820 DATE: April 13, 2021 REMANDED Entitlement to service connection for a stomach disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1964 to January 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision by the Department of Veterans Affairs (VA). This case was remanded in March 2020 and August 2020 for further development. In February 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. After reviewing the evidence of record, and in light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the issue of service connection for a gastrointestinal disability to encompass any stomach disability. Entitlement to service connection for a stomach disability. The Veteran is diagnosed with gastroesophageal reflux disease (GERD). See, e.g., February 2020 private treatment records. During service, he participated in low pressure chamber flights to extreme altitudes. See, e.g., May 1967 military personnel records. During service, he reported epigastric abdominal pain, cramping, loose watery bowel movements, and nausea and was diagnosed with acute enteritis. See May 1964 service treatment records (STRs). His discharge medical examination reflects that he reported occasional indigestion, but no medication was required. See December 1967 STRs. Shortly after service, he reported that he would have increased gas in his intestines during his flights in service. See January 1969 VA Form 9. He testified that he had acid reflux when he got out of service. See February 2020 Board hearing. An October 2020 VA examiner opined it was less likely than not that the Veteran’s GERD was related to service. The examiner relied on the absence of evidence in STRs and discounted the Veteran’s report of symptoms because it was not supported in medical evidence. Additionally, the examiner discussed that GERD was not noted in medical records until 2019. Because the examiner relied on the absence of evidence and improperly negated credible lay evidence, the opinion is inadequate. A January 2021 VA examiner likewise opined that it was less likely than not that the Veteran’s GERD was related to service. This time, the examiner did not discuss the Veteran’s report of symptoms at all. As a result, the opinion is inadequate and remand for a new opinion is necessary. The matter is REMANDED for the following action: 1. The AOJ should arrange for a VA telehealth interview or examination of the Veteran to determine the nature and likely cause of his GERD. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and interview of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: Is it at least as likely as not (50% or greater probability) that the Veteran’s GERD was either incurred in or otherwise related to his military service? Please explain why. The examiner may not rely solely on the absence of medical evidence in STRs or treatment records immediately after service. The examiner must consider the Veteran’s testimony that he had acid reflux when he got out of service and the separation medical examination that reflects occasional indigestion. 2. If upon completion of the above action the issue remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Sandler, 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.