Citation Nr: 21040853 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 13-00 939 DATE: July 7, 2021 REMANDED Entitlement to service connection for peptic ulcer disease (PUD), to include as secondary to service-connected disabilities as well as medications taken for treatment of those disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from December 1972 to March 1979. This matter comes before the Board of Veterans' Appeals (Board) from an August 2011 rating decision. In June and July 2015, the Board remanded this matter for additional development. Thereafter, the Veteran's claim of service connection for a stomach disorder was denied in a November 2017 Board decision. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In August 2018, the Court granted the parties' Joint Motion for Partial Remand. In February 2019, October 2019, January 2020, September 2020, and March 2021, the Board remanded this matter for additional development. Entitlement to service connection for PUD, to include as secondary to service-connected disabilities as well as medications taken for treatment of those disabilities, is remanded. The Board cannot make a fully-informed decision on this matter, as the VA examiners who drafted the October 2019, February 2020, and April 2021 VA medical opinions may have applied the wrong aggravation standard for secondary service connection. The VA examiners each opined that there was no evidence that the claimed PUD was aggravated beyond its natural progression by the Veteran's service-connected conditions. However, the opinions are unclear as to whether they are addressing permanent worsening or temporary worsening. The Court recently held that for secondary service connection claims, the standard for aggravation is any increase in disability, even a temporary one, not permanent worsening. See Ward v. Wilkie, 31 Vet. App. 233 (2019). In addition, the April 2021 VA examiner noted that the main causes of PUD were Helicobacter pylori bacteria and the use of NSAIDs. The February 2020 and April 2021 VA examiners noted that although the Veteran had been prescribed NSAIDs for treatment of service-connected conditions, a December 2015 upper GI series did not show evidence of PUD. However, the Board notes that evidence of record clearly showed findings of PUD in 2019. As the wrong standard may have been used in the VA medical opinions of record and rationale regarding whether use of NSAIDs caused or aggravated the Veteran's PUD was inadequate, a remand is needed to obtain an additional medical opinion to clarify whether the Veteran's claimed PUD was caused or aggravated by his service-connected disabilities as well as medications such as NSAIDs and Amitriptyline used to treat those disabilities. Finally, updated VA treatment records from Atlanta VAMC dated since June 2021 should be obtained and associated with the electronic claims file. The matter is REMANDED for the following actions: 1. Obtain updated treatment records pertaining to the Veteran's claimed PUD from Atlanta VAMC for the time period from June 2021 to the present and associate them with the record. 2. Thereafter, obtain a VA medical opinion to clarify the etiology of the Veteran's claimed PUD from an appropriate examiner. If an opinion cannot be provided without an examination, one should be provided. The electronic claims file must be made available to the examiner, and the examiner must specify in the report that the file has been reviewed. Based on a review of the evidence of record and with consideration of the Veteran's statements, the examiner should opine as to whether any currently or previously diagnosed PUD was caused by or aggravated (worsened) by the Veteran's service-connected disabilities (as well as medications such as NSAIDs and Amitriptyline used to treat those disabilities). In doing so, the examiner should acknowledge and discuss the findings in the post-service VA and private treatment records as well as the December 2015, October 2019, January 2020, February 2020, November 2020, and April 2021 VA examination reports/medical opinions. The examiner is advised that permanent worsening of the condition beyond its natural progression need not be shown. The possibility of temporary worsening should be addressed. Aggravation refers to any incremental increase in disability, any additional impairment of earning capacity in non-service-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). The Veteran is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on his claim. 38 C.F.R. § 3.655. 3. After completing the above actions and any other necessary development, the claim on appeal must be re-adjudicated, taking into consideration all relevant evidence associated with the record since the May 2021 SSOC. If the benefit on appeal remains denied, a SSOC must be provided to the Veteran and his attorney. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. D. Deane, 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.