Citation Nr: 21022808 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 08-36 756 DATE: April 19, 2021 REMANDED Entitlement to service connection for gastrointestinal reflux disease (GERD), including as secondary to the Veteran’s service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1969 to October 1970. This matter again comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. After remanding this matter in August 2010, the Board denied entitlement to service connection for GERD in a May 2012 decision. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). By way of a March 2013 Order, the Court vacated and remanded the Board’s May 2012 decision pertaining to this issue. Since that time, the Board has remanded this matter in October 2013, October 2015, May 2017, and December 2020. 1. GERD In the May 2017 remand, the Board requested an addendum opinion regarding this matter specifically addressing various treatises and remarks submitted by the Veteran and his representative in November 2016. An opinion received in May 2019 did not address said remarks and/or treatises. See May 2017 Board Decision; May 2019 VA Medical Opinion (labeled C&P Examination). Accordingly, the Board again remanded this matter in December 2020, noting that the RO did not substantially comply with remand directives and requested that a new opinion be provided which would address said remarks and treatises. See December 2020 Board Decision; Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board acknowledges receipt of a February 2021 opinion concluding that the Veteran’s GERD is less likely than not related to his service-connected disabilities and/or medications taken for said disabilities. However, again, the clinician providing the opinion did not address the remarks and treatises submitted in November 2016. See February 2021 VA Opinions (labeled C&P Examinations). Again, the RO did not substantially comply with the Board’s previous remand directives. See Stegall, 11 Vet. App. at 271; D’Aries, 22 Vet. App. at 105. Consequently, the Board must remand this matter again for an adequate opinion addressing all competent medical and lay evidence of record as to the nature and etiology of the Veteran’s GERD. The matters are REMANDED for the following action: 1. Forward the claims file to an appropriate clinician to ascertain the nature and etiology of the Veteran’s GERD. The entire claims file, including a copy of this remand, must be made available to the clinician, who must note its review. If the clinician determines that an examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be provided. (a) The clinician should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s GERD manifested during, or is the result of, his active duty service. (b) The clinician should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s GERD was either (i) caused or (ii) aggravated by his service-connected disabilities, to include medications taken to treat said service-connected disabilities. NOTE: With respect to the question concerning aggravation, the clinician is advised that aggravation under 38 C.F.R. § 3.310 does not require “permanent worsening” of the nonservice-connected disability. If aggravation is found, the clinician should attempt to identify the baseline level of severity. In formulating his or her opinions, the clinician should consider and address all competent medical and lay evidence of record, including, but not limited to: (i) The Veteran’s service treatment records; (ii) The Veteran’s VA medical records; (iii) The Veteran’s private medical records; (iv) The Veteran’s remarks to Supplemental Statement of the Case submitted in November 2016; (v) Kay Jankowsi, Ph.D., PTSD and Physical Health, National Center for PTSD Fact Sheet (submitted in November 2016 by the Veteran); (vi) May 2007 Testimony by Thomas R. Insel, M.D., Director of National Institute of Mental Health before United States House of Representatives Committee on Oversight and Government Reform (submitted in November 2016 by the Veteran); and (vii) The Veteran’s competent lay statements, including to his various medical providers, regarding the onset and continuity of his symptomatology. If the clinician determines that the Veteran’s GERD is less likely than not due to his active duty service and/or is less likely than not caused and/or aggravated by his service-connected disabilities, including medications taken to treat said service-connected disabilities, the clinician should discuss what other factor(s) caused the disorder. In other words, the clinician should determine the most likely etiology of the Veteran’s GERD. A complete rationale must be provided for all opinions and conclusions reached. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Seserman 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.