Citation Nr: 22019367
Decision Date: 04/01/22	Archive Date: 04/01/22

DOCKET NO. 16-62 660
DATE: April 1, 2022

REMANDED

Entitlement to a rating higher than 10 percent for gastroesophageal reflux disease (GERD) with Gilbert's syndrome is remanded.

REASONS FOR REMAND

The Veteran served on active duty in U.S. Army from October 1992 to October 1996. 

This appeal last was before the Board in June 2021. At that time, the issue of entitlement to service connection for a liver disability was remanded for further development. The Board notes that, in a January 2022 rating decision, service connection for Gilbert's syndrome (liver disability) was granted and included in the evaluation with the service-connected GERD. As the benefit sought on appeal has been granted, the Board no longer has jurisdiction over this issue.

The Veteran appeals the denial of a rating higher than 10 percent for his service connected GERD with Gilbert's syndrome. The Veteran's disability is rated under Diagnostic Codes 7345-7346. In relation to the claim, the Veteran was last examined by VA in October 2021. The Veteran's representative, however, has since argued that the VA examination is inadequate as it is not clear if the ameliorating effects of medication were expressly factored into the evaluation. 

In Jones v. Shinseki, 27 Vet. App. 56, 61 (2012), the Court found that, when considering a claim for an increased rating, the Board should not consider the ameliorative effects of medication unless those effects are expressly contemplated by the relevant rating criteria. 38 C.F.R. § 4.114, Diagnostic Code (DC) 7346, used to rate GERD, does not mention the effects of medication. While the examiner noted in the examination report that the "Veteran now requires use of prescription medicine to control GERD symptoms which he was not taken on previous VA exam," it is unclear from the record whether the assessments made by the October 2021 VA examiner as to the nature, frequency and severity of the Veteran's GERD symptoms were made without considering the ameliorating effects of his reported medication. As such, the Board finds that a remand is warranted so that an examination and opinion can be obtained that describes the Veteran's likely GERD symptoms in the absence of medication.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA compensation examination to determine the nature and severity of his GERD. The examiner must be provided access to the electronic claims record. All appropriate tests and studies should be accomplished, and all clinical findings should be reported in detail. 

The examiner is asked to identify and opine on what the Veteran's symptoms would be without the ameliorative effects of medication. If such opinion is not medically feasible, the examiner should provide a rationale why. A complete rationale should be provided for any opinion expressed.

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2. Thereafter, the AOJ should consider all of the evidence of record and readjudicate the issue on appeal. If the benefits sought are not granted, issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his representative an opportunity to respond.

 

 

T. MAINELLI

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T.S. Willie

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.