Citation Nr: 22018804 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 17-36 876 DATE: March 30, 2022 REMANDED Entitlement to service connection for a gastrointestinal condition, claimed as irritable bowel syndrome (IBS), is remanded. Entitlement to an initial disability rating in excess of 30 percent for service-connected post-traumatic stress disorder (PTSD) with depressive disorder is remanded. Entitlement to an initial disability rating in excess of 10 percent for service-connected gastroesophageal reflux disease (GERD) is remanded. Entitlement to an initial compensable disability rating for service-connected migraine headaches is remanded. Entitlement to an initial compensable disability rating for service-connected chronic lumbar strain for the period from May 1, 2006, through August 16, 2015, and in excess of 10 percent from August 17, 2015, forward is remanded. INTRODUCTION The Veteran served honorably on active duty in the United States Army during the Gulf War Era, from September 1999 to May 2000 and from November 2000 to April 2006, including service in the Southwest Asia theater of operations. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2016 Rating Decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In October 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing. A transcript of the hearing is contained within the claims file. REASONS FOR REMAND Entitlement to service connection for a gastrointestinal condition, claimed as IBS, is remanded. The Veteran seeks entitlement to service connection for a gastrointestinal condition claimed as IBS. The claim has been recharacterized to reflect the Veteran's contentions and the evidence more accurately. In December 2015, the Veteran underwent a VA examination related to this claim. For the reasons set forth below, the Board finds the VA examiner's opinion rationale inadequate for adjudication purposes and, as a result, remand is required. See Barr v. Nicholson, 21 Vet. App. 303 (2007). First, the VA examiner's statements that, "[t]here is no objective medical evidence that [the Veteran] suffered from IBS symptoms in service" and that his service treatment records (STRs) are "silent for IBS," ignores multiple references to in-service symptoms including chronic diarrhea, nausea, and vomiting. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding the Board may reject a medical opinion based upon an inaccurate factual basis). Next, despite the foregoing documented in-service symptoms, the VA examiner's heavy, if not exclusive, reliance upon a perceived lack of documented complaints or treatment for his symptoms during active duty and until December 2015, "9 years after service," without more, is an insufficient basis for the abbreviated negative nexus opinion. See Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). This is particularly significant when the VA examiner's opinion rationale is devoid of discussion regarding the Veteran's competent self-reports as to such factors as in-service events (i.e., causation) and onset and progression of symptoms (i.e., chronicity), as is the case here. See Dalton v. Peake, 21 Vet. App. 23 (2007) (a medical opinion which does not consider the Veteran's reports of symptoms and history, even if recorded in the course of the examination, is inadequate). Finally, because the Veteran's claim may involve a disability due to an undiagnosed illness or medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms such as functional gastrointestinal disorders, the lack of a formal diagnosis does not necessarily preclude entitlement to service connection. 38 C.F.R. § 3.317. Based upon the foregoing, the Board finds the VA examiner's opinion as written is not supported by adequate analysis of the relevant evidence under review, fully articulated, or based upon sound reasoning and data. See McCray v. Wilkie, 31 Vet. App. 243, 257 (2019). Thus, remand is required to afford the Veteran a VA examination and to procure a medical nexus opinion adequate for adjudication purposes. Entitlement to an initial disability rating in excess of 30 percent for service-connected PTSD with depressive disorder is remanded. Entitlement to an initial disability rating in excess of 10 percent for service-connected GERD is remanded. Entitlement to an initial compensable disability rating for service-connected migraine headaches is remanded. Entitlement to an initial compensable disability rating for service-connected chronic lumbar strain for the period from May 1, 2006, through August 16, 2015, and in excess of 10 percent from August 17, 2015, forward is remanded. The Veteran last underwent VA examinations assessing his service-connected PTSD, GERD, migraine headaches, and chronic lumbar strain in December 2015. However, in October 2021, the Veteran testified that his disabilities have worsened since the last VA examinations. For example, he testified to worsening PTSD symptoms such as exhibiting aggressive speech and experiencing flattened mood, difficulty establishing and maintaining effective social relationships, social isolation, and frequent suicidal ideations. The Veteran also testified to worsening GERD symptoms such as heartburn, nausea, chest or abdominal pain that radiates into upper extremities, and occasional vomiting and painful swallowing. Further, he testified to worsening migraine headache symptoms including multiple prostrating attacks monthly. Finally, the Veteran testified to worsening chronic lumbar strain symptoms such as reduced ability to bend, as well as pharmacologic and chiropractic treatment. As there is evidence of a worsening of these disabilities since the last VA examination, which were performed over six years ago, the claims must be remanded for new examinations to determine the current severity of the Veteran's service-connected PTSD, GERD, migraine headaches, and chronic lumbar strain disabilities. See Snuffer v. Gober, 10 Vet. App. 400 (1997). Finally, as the Veteran testified to receiving ongoing VA treatment, and because the most recent CAPRI records are dated January 2019, on remand updated VA treatment records must be obtained and associated with the claims file. Accordingly, these matters are REMANDED for the following action: 1. Obtain all updated VA treatment records and associate them with the claims file. If VA determines any requested records do not exist or that further efforts to obtain them would be futile, issue a Formal Finding outlining the steps taken to assist the Veteran and notify him and his representative accordingly. 2. Schedule the Veteran for an in-person VA examination with a physician possessing the necessary expertise to fully assess and provide an opinion regarding the nature, severity, and likely etiology of the Veteran's gastrointestinal condition(s) claimed as IBS. The examiner MUST obtain a full history from the Veteran. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as in-service events and observable in-service and post-service symptomology and functional limitations. All pertinent symptomology and functional limitations, including when initially manifested and any progression, MUST be reported in detail. Based upon a review of all pertinent documents in the Veteran's claims file including medical treatment and examination records, lay statements, and the examination results, the examiner MUST offer an opinion based upon an accurate medical history, with clear conclusions and supporting data and a reasoned medical explanation connecting the two, as to: (a.) Whether it is AT LEAST AS LIKELY AS NOT (i.e., 50 percent probability or greater) the Veteran's gastrointestinal condition(s), claimed as IBS, manifested during active duty service OR is due to, related to, or otherwise etiologically associated with an in-service event, injury, or disease, to include in-service environmental exposure in the Southwest Asia theater of operations. (b.) Whether the Veteran's gastrointestinal symptomology, even if episodic/intermittent in nature, AT LEAST AS LIKELY AS NOT (i.e., 50 percent probability or greater) represents a chronic disability resulting from an undiagnosed illness, OR a medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms such as functional gastrointestinal disorders (i.e., a diagnosed illness without conclusive pathophysiology or etiology characterized by overlapping symptoms and signs), OR any combination of both. In offering the above opinions the examiner MUST consider, discuss, and reconcile as necessary all pertinent lay and medical evidence of record including, but not limited to, the following: (a.) STRs dated April, July, and August 2002 noting diarrhea, nausea, and vomiting; (b.) the Veteran's October 2021 testimony regarding, for example, onset of symptoms; and (c.) VA treatment records noting IBS. The examiner is advised that while a lack of supportive medical evidence is a relevant factor, the mere absence of evidence does not equate to unfavorable evidence. The Veteran's lay statements and reports of causation, onset, and symptomology MUST be considered and discussed. A complete and thorough rationale for all opinions expressed, with references to pertinent evidence of record and as warranted, supportive medical literature MUST be provided. 3. Schedule the Veteran for an in-person VA examination with a physician(s) possessing the necessary expertise to fully assess and provide opinions regarding the nature and severity of the Veteran's service-connected PTSD, GERD, migraine headaches, and chronic lumbar strain FOR THE ENTIRE PERIOD ON APPEAL. The examiner MUST obtain a full history from the Veteran. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology and functional limitations. All pertinent symptomology and functional limitations, including when initially manifested and any progression, for the entire period on appeal MUST be reported in detail. Based upon a review of all pertinent documents in the Veteran's claims file including medical treatment and examination records, lay statements, and the examination results, the examiner MUST offer an opinion based upon an accurate medical history, with clear conclusions and supporting data and a reasoned medical explanation connecting the two, providing a full description of the Veteran's service-connected PTSD, GERD, migraine headaches, and chronic lumbar strain, including all signs and symptoms necessary for evaluating his disabilities under the applicable rating criteria FOR THE ENTIRE PERIOD ON APPEAL. In offering the above opinions the examiner MUST consider, discuss, and reconcile as necessary all pertinent lay and medical evidence of record including, but not limited to, the Veteran's October 2021 testimony regarding worsening symptomology. The examiner is advised that while a lack of supportive medical evidence is a relevant factor, the mere absence of evidence does not equate to unfavorable evidence. The Veteran's lay statements and reports of symptomology and functional limitations for the entire period on appeal MUST be considered and discussed. A complete and thorough rationale for all opinions expressed, with references to pertinent evidence of record and as warranted, supportive medical literature MUST be provided. (Continued on next page) T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.