Citation Nr: 21023151 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 13-33 599 DATE: April 20, 2021 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for chest pain is denied.   FINDINGS OF FACT 1. The Veteran’s GERD is not due to or a result of his active service. 2. The Veteran does not have a separate disability involving chest pain. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for chest pain are not met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from December 1966 to December 1968, to include service in Vietnam. His decorations include the Combat Infantryman Badge, the Air Medal, and the Bronze Star Medal with “V” device. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a March 2010 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In February 2017, January 2019, and May 2020, the Board remanded the claims for additional development. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). “Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (internal citation omitted). The requirement of a “current disability” is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The standard is whether a disability exists at the time the claim was filed. See Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). 1. Entitlement to service connection for GERD The Veteran contends that the symptoms of his diagnosed GERD began during his active service and have continued since then. Upon review of the evidence of record, the Board finds that service connection for GERD, and any related gastroesophageal disability, is not warranted. Initially, the Veteran has a current diagnosis as reflected by the medical evidence of record. Post-service, private treatment records reflect that in September 2000, the Veteran complained of some pain in the epigastric area plus bloating and some difficulty swallowing. He reported pressure with urination. His recent upper gastrointestinal tract radiography (upper GI) was negative. He was assessed with heartburn. In July 2001, the Veteran an esophagogastroduodenoscopy (EGD) which revealed some gastritis as well as H. Pylori positivity. He was given medication as treatment. In September 2001, the clinician noted that the Veteran has a history of gastritis documented on endoscopy. In October 2003, GERD was noted as an active problem and/or diagnosis. Private treatment records reflect that in December 2008, the Veteran underwent an EGD which revealed dysphagia, gastritis (possibly related to underlying nonsteroidal anti-inflammatory drugs) Private treatment records reveal that in December 2012, the Veteran was assessed with dysphagia, not otherwise specified. As the current disability requirement has been met, the question remains as to whether there is a nexus between the disability and service. Service treatment records (STRs) reflect that in October 1967, the Veteran complained of nausea and vomiting. He was given medication and reported back to regular duty. In December 1967, the Veteran complained of pain the right lower quadrant with urination. In March 1968, the Veteran complained of burning on urination. This evidence confirms the reported symptoms during service. This claim has been remanded numerous times in an effort to obtain an adequate opinion as to whether the symptoms in service are related to the current condition. In July 2017, a VA clinician explained that the STRs were silent for symptoms or diagnosis of GERD or reflux; however, the examiner did not address the Veteran’s competent lay statements and did not thoroughgoingly discuss his in-service symptoms. Additionally, the examiner did not address the December 2008 clinician’s indication that gastritis was possibly related to underlying nonsteroidal anti-inflammatory drugs and the heartburn dated back to the year 2000. A July 2019 VA clinician only noted that there was no diagnosis of GERD in service. Hence, the claim was remanded for a new opinion. Upon remand, a December 2020 opinion was given, and it is adequate and therefore in substantial compliance with the May 2020 Board remand directives and is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The examiner opined that the condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner reported that the 2019 medical opinion was correct. The clinician noted that there is no evidence of GERD in service. There is no legible separation examination, but the October 1967 events were clearly an isolated episode of nausea and vomiting with no further record of the gastrointestinal condition. The examiner explained that nausea and vomiting are not the hallmarks of incurred, which usually presents as pyrosis. Per the Veteran’s own history, the condition arose in or around 2008; 40 years post service. There was no nexus established in service and there was no care proximate to service or for decades. Therefore, the examiner considered the Veteran’s claims to the contrary, but concluded that the medical evidence does not support the onset of the Veteran’s GERD while in service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The December 2020 VA clinician did not address the December 2008 statement that gastritis was possibly related to underlying nonsteroidal anti-inflammatory drugs as noted in the body of the May 2020 Board remand. However, the Board did not direct the examiner to do so. Otherwise, there is no reasons or bases requirement imposed on examiners. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Given that, for the reasons stated above, the December 2020 opinion was adequate and probative, the Board finds that there was compliance with the essential objectives of the remand instructions and therefore substantial compliance. Another remand is therefore not warranted in these circumstances. See Stegall v. West, 11 Vet. App. 268 (1998); see D’Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). In January 2013, the Veteran’s attorney argued that in October 1967, the Veteran was seen in-service for complaints of vomiting and pain and given medication to control severe nausea and vomiting. He was seen again for pain in the right lower quadrant and urination. In March 1968, the Veteran was seen for complaints of burning on urination which they argue are symptoms of typical patients with GERD. The attorney inserted a website in support of this statement (however, the link inserted did not bring up an article or any medical treatise). The attorney went on to report that in July 1968, the Veteran reported shortness of breath and palpitation of the heart. The attorney argued that these symptoms are typically used to identify GERD in a patient and inserted the same link to the website in support of his argument. The attorney reported that in August 1985, the Veteran was seen with complaints of abdominal pain. In May 1987, the Veteran was diagnosed with an upper respiratory infection. In September 1987, he was diagnosed with cystopyelitis. In September 2000, the Veteran was diagnosed with heartburn. In June 2001, he was diagnosed with a chronic active gastritis including mild chronic inflammation with small bowel mucosa. In May 2002, he was diagnosed with GERD with dysphagia. To the extent that the Veteran, including through his representative, has opined that his GERD is related to service, they are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of gastrointestinal medication, including interpretation of diagnostic testing, the risk factors and presenting symptoms of diseases in this area, and the application of those factors to the instant case. It is outside the competence of the Veteran and representative in this case because the record does not show that they have the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiner’s opinion. The Board has also considered the medical literature the Veteran attempted to submit in connection with his contention that complaints of burning on urination and shortness of breath are early signs of GERD. As noted, the links cited in the brief no longer work. Even assuming the representative’s brief accurately cites the article, an excerpt from a generic medical text, such as here, which does not apply medical principles regarding causation or etiology to the facts of the individual Veteran's case generally will not provide sufficient evidence, standing alone, to serve as the basis for an award of service connection, but can provide important support for service connection, particularly when interpreted by a medical professional. McCray v. Wilkie, 31 Vet. App. 243, 255 (2019). Here, the articles provide important evidence to help the Board understand the Veteran’s claim, but the VA examiner’s opinion remains more probative as the VA examiner was a medical professional with expert knowledge in this area and considered the particular facts of this Veteran’s case. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim of service connection for GERD. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for chest pain The Veteran contends that his chest pain is due to his active service. Upon review of the evidence of record, the Board finds that service connection for chest pain is not warranted. The Board concludes that the Veteran does not have a current diagnosis of a chest disability and has not had a disability manifested by chest pain with functional impairment of earning capacity at any time during the pendency of the claim or recent to the filing of the claim. Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018) (a diagnosis is not required to meet the current disability requirement and pain alone can constitute disability if it causes impairment in earning capacity); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the current disability requirement is met by a showing of disability at any time during the claim or approximate thereto). STRS do not reflect a diagnosis, treatment, or symptoms of chest pain. Post-service, in January 1997, emergency department treatment notes reflect that the Veteran complained of pain on the right side of his chest, worse with deep inspiration. Additionally, there was pain to the right upper back. He denied any trauma. The chest wall revealed some reproducible tenderness to the right anterior chest wall. The chest X-ray was normal. At that time, the clinician felt like it was just musculoskeletal and chest wall pain. In September 2002, private treatment records reflect that the Veteran was seen for chest pain. In September 2012, private treatment records reflect that the Veteran complained of chest pain. The clinician noted that it was negative for claudication, edema, and irregular heartbeat/palpations. The Veteran’s chest pain was associated with hypertension and hyperlipidemia. Radiology of the chest was unremarkable for age. Likewise, in December 2013, the Veteran reported chest pain and palpations which the clinician associated with hyperlipidemia, hypertension, and diabetes. In January 2013 correspondence, the Veteran’s attorney reported that the Veteran had pain in the back, neck, and chest due to numerous aerial mission assaults over hostile territory involving parachute jumps. The July 2017 DBQ report reflects that the date of onset of the symptoms of chest pain is 1968. The Veteran reported that the condition began shortly after discharge from the military where he began to have chest discomfort. The condition has worsened in that there was a “irregular heartbeat.” A stent was placed in 15 years prior to the DBQ. The clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, they reported that a review of the record reveals that the Veteran was initially seen in 1997 for chest pain and discomfort which was initially related to a C5-C6. They concluded that the examination did not reveal any scars or disfiguration of the chest wall which would support the shrapnel injuries. Therefore, they concluded that it is less likely than not that the condition occurred while serving on active duty. Private treatment notes from December 2018 reflect that the Veteran’s chest pain was noted as a new problem. The current episode started in the past seven days. The onset was sudden, constant, and unchanged. The pain was present in the substernal region. The clinician noted increased GERD lately and indigestion. The clinician noted that he suspected GERD. The September 2019 DBQ report reflects that the Veteran reported chest pain with a date of onset of over 40 years. He was unsure of the details but reported that it happened in Vietnam. The clinician noted that there is no medical literature to support the notion that frequent parachute jump leads to the chest pain that the Veteran is complaining of. The Veteran’s records did not show similar complaint when he was actively jumping from parachutes which would expect if the jumping is causing chest pain. The clinician reported that unlike bone or joint conditions, this type of injury is not a delayed onset one that could be experienced with jumping. Therefore, the Veteran’s claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The clinician went on to explain that the Veteran’s chest pain is described as a burning retrosternal pain like a heart burn due to reflux. The clinician noted that the Veteran’s endoscope shows reflux. They concluded that this does not cause functional limitation. The examiner’s opinion is probative, because it is based on an accurate and comprehensive medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran is competent to report the problems he has with chest pain, and his descriptions are credible. However, he has not shown that his chest pain has caused functional impairment of earning capacity. The September 2019 VA clinician specifically found that the Veteran’s chest pain does not cause functional limitation. Additionally, the Veteran’s chest pain has been associated with GERD as well as his service-connected disabilities including coronary artery disease, diabetes, and cervical and degenerative spine disease. (Continued on the next page)   For the above stated reasons, the preponderance of the evidence weighs against a finding that the Veteran currently has a separate disability related to chest pain, to include consideration of chest pain symptoms causing functional impairment in earning capacity pursuant to Saunders. As there is currently no indication of a diagnosed medical condition or symptoms causing a functional impairment apart from a different medical condition, the claim must be denied. See Brammer, 3 Vet. App. at 225; Romanowsky, 26 Vet. App. at 293; McClain, 21 Vet. App. at 321. The benefit of the doubt doctrine is therefore not for application and this claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Corey Bosely Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laroche, N. 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.