Citation Nr: 21030234 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-11 934 DATE: May 18, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as secondary to service-connected degenerative disc disease, lumbar spine, is remanded. REASONS FOR REMAND This matter was most recently before the Board of Veterans' Appeals (Board) in February 2021, when it was remanded, in pertinent part, for a new opinion addressing whether the Veteran's GERD is at least as likely as not proximately due to or aggravated by nonsteroidal anti-inflammatory drug (NSAIDs) use associated with his service-connected low back disability. The Agency of Original Jurisdiction (AOJ) obtained a new opinion regarding the Veteran's claim in March 2021. Unfortunately, the March 2021 opinion is inadequate to make an informed decision on the Veteran's claim. Although the March 2021 examiner appears to have provided an adequate rationale regarding causation in the context of secondary service connection, the Board finds her aggravation opinion is conclusory in nature and does not adequately address the evidence of record. The March 2021 examiner determined she could not determine the baseline of the Veteran's GERD due to lack of medical evidence and insufficient history of condition, rendering her unable to state if the GERD was aggravated beyond its natural progression by the Veteran's NSAID usage; however, there was no discussion of the Veteran's lay reports or medical records to support her conclusion in this regard. The Board notes the Veteran's prison treatment records show he first sought treatment for gastrointestinal symptoms in November 2013 when he was started on Prilosec and received a referral to a specialist for further treatment. There are several notations of a diagnosis of GERD in prison treatment records following the initial treatment in November 2013 until the Veteran's release from prison in October 2016, after which he began seeking treatment through the Veterans Health Administration. The Veteran's treatment for GERD is well-documented in VA treatment records with symptoms first being described as "indigestion [with] each meal" during his initial VHA appointment to "severe GERD symptoms and loss of appetite" as recently as September 2020. Since the March 2021 examiner failed to discuss the Veteran's documented medical history, the Board finds her opinion is inadequate to make an informed decision on the Veteran's claim, requiring a remand for new opinion to ensure compliance with its prior remand directives and VA's duty to assist. The matter is REMANDED for the following action: Obtain a new opinion regarding the Veteran's service connection claim for GERD, preferably with an examiner other than the March 2021 examiner. The selected examiner must provide an opinion addressing whether the Veteran's GERD is at least as likely as not (50 percent probability or greater) proximately due to, or aggravated by, NSAID usage associated with his service-connected low back disability. The opinion must explicitly address both causation and aggravation to be deemed adequate. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. The examiner must be further advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examination report must include a complete rationale for each conclusion contained therein, to include a potential baseline determination in the context of aggravation. The rationale must at minimum discuss the Veteran's documented treatment history for GERD beginning in November 2013, when he was started on Prilosec, as noted in prison treatment records, continuing through his release from prison in October 2016 and then in VA treatment records with his initial symptoms being described as "indigestion [with] each meal" during his initial VHA appointment in October 2016 and progressing to "severe GERD symptoms and loss of appetite" as recently as September 2020. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. S. Kyle, 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.