Citation Nr: 21022159 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 14-04 705 DATE: April 14, 2021 REMANDED Service connection for a gastrointestinal disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1974 to March 1975. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2010 rating decision by the Department of Veterans Affairs (VA). This issue was remanded by the Board in April 2016 and April 2018, it has since been re-assigned to the undersigned. In November 2015, the Veteran testified at a Board hearing before a Veterans Law Judge (VLJ) no longer at the Board; a transcript of that hearing is of record. In February 2021, the Veteran was offered the opportunity to testify at a hearing before another VLJ. See 38 U.S.C. § 7107(c); 38 C.F.R. § 20.604. Because the Veteran did not respond to this letter within 30 days, the Board will proceed with adjudication. The Board most recently remanded this issue to obtain outstanding VA treatment records and obtain an adequate opinion regarding whether the Veteran’s gastrointestinal disability was related to her service-connected left knee disability. The remand noted that a December 2017 VA examination confirmed a diagnosis of GERD. The Veteran underwent a new VA examination in November 2019. The examiner stated that GERD was clinically noted but never confirmed. Regarding the Veteran’s service-connected left knee disability and the medication treating this disability, the Veteran takes NSAIA medications for joint issues. These medicines can result in gastritis and even peptic ulcer disease, but are not causative of GERD and do not affect esophageal reflux. The Veteran has not been diagnosed with gastritis or gastric/duodenal ulcer. The examiner opined that the Veteran never developed any disability related to NSAIA use. The examiner further opined that no GI disturbance has been aggravated beyond natural progression by any medication or service-connected condition. The examiner also discussed the Veteran’s obesity and how it relates to her GI disability. The examiner noted that the Veteran possibly has GERD, but more likely post-bypass GI symptoms and nutrient deficiencies. The Veteran underwent bypass surgery for obesity, which is unrelated to NSAIA medication. The examiner stated that the Veteran’s obesity is more likely than not a significant part of any weight bearing region joint problem. The examiner then stated that there is no known association between knee injury and obesity development. Obesity is multifactorial and associated largely with diet and activity and genetic factors. Multiple studies in fact show no weight loss after total knee replacement patients whose mobility is severely limited before surgery and improved after. The examiner later stated that the Veteran’s many GI disturbances are more likely related to the gastric bypass performed for exogenous obesity. The Board finds that the November 2019 VA examiner’s opinion is internally inconsistent and therefore inadequate for appellate review. There are several conflicting statements regarding the relationship between the Veteran’s obesity and gastrointestinal disability. The Board notes that obesity is not a disability for purposes of VA benefits; hence, it cannot be service connected on a direct basis. See Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). However, indirect secondary service connection can be granted with obesity acting as an “intermediate step.” See VAOPGCPREC 1-2017 (Jan. 6, 2017). Specifically, a grant is warranted (1) if the service-connected disability caused the Veteran to become obese, (2) if obesity was a substantial factor in causing a subsequent disability, and (3) if the subsequent disability would not have occurred but for obesity. Id. The November 2019 VA examination contains the examiner’s conclusions that the Veteran’s obesity is likely a significant part of any weight bearing region joint problem and that the Veteran’s many GI disturbances are likely related to the gastric bypass performed for exogenous obesity. The Veteran, through her representative, asserts that she gained weight after total knee surgery as she was unable to maneuver properly for any exercise and that her gastrointestinal issues were initially caused by the pain medication for her knee after surgery, therefore necessitating the bypass surgery. See August 2020 Appellant’s Post-Remand Brief. On remand, an addendum opinion is required to help inform the Board’s decision on whether obesity is an intermediate step between the Veteran’s service-connected left knee disability and her currently diagnosed gastrointestinal disability. The matters are REMANDED for the following action: 1. The AOJ should obtain updated VA and non-VA treatment records. 2. The AOJ should obtain an addendum opinion, from an appropriate clinician, to determine the following: a. Is the Veteran’s obesity at least as likely as not due to her service-connected left knee disability? b. Is the Veteran’s obesity at least as likely as not aggravated by her service-connected left knee disability? c. If, and only if, the Veteran’s obesity is deemed to have been caused or aggravated by her service-connected left knee disability, would the Veteran’s gastrointestinal disability not have occurred but for obesity caused or aggravated by the Veteran’s service-connected left knee disability? The VA examiner should note that the Veteran’s obesity is not a disease or disability for VA benefits purposes; however, it may act as an intermediate step between a service-connected disability and a current disability that may be service-connected on a secondary basis. To determine whether any weight gain or obesity is an intermediate step between the Veteran’s service-connected left knee disability and a gastrointestinal disability, the examiner should fully answer the above questions. The examiner is asked to provide a rationale to support the opinion(s) that is as detailed as is reasonably possible. The examiner is asked to consider and, as reasonable and appropriate, to discuss, the Veteran’s lay statements. In addition, the examiner should address the November 2019 VA examiner’s conclusions that the Veteran’s obesity is more likely than not a significant part of any weight bearing region joint problem and that the Veteran’s many GI disturbances are likely related to the gastric bypass performed for exogenous obesity. (Continued on the next page)   In rendering the requested opinions, the examiner must consider all relevant evidence of record. A complete and thorough rationale must be provided for all opinions. If the examiner is unable to offer the opinions requested, he or she must explain in detail why that is the case. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Kerner, 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.