Citation Nr: 23019666 Decision Date: 03/30/23 Archive Date: 03/30/23 DOCKET NO. 15-29 702 DATE: March 30, 2023 REMANDED Entitlement to service connection for a gastrointestinal (GI) disorder is remanded. REASONS FOR REMAND The Veteran had active service from October 1980 to September 1986. This matter comes before the Board of Veterans Appeals (Board) on appeal from a June 2014 rating decision issued by the Agency of Original Jurisdiction (AOJ), Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural history, in September 2018 and July 2021, the Board remanded the appeal to provide the Veteran with a medical opinion to adequately address the nature and etiology of her GI disorder. Most recently, in March 2022, the Board found substantial compliance with its prior directives and denied, in part, entitlement to service connection for the foregoing issue. The Veteran then appealed the denial to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a November 2022 Joint Motion for Partial Remand (JMPR), the Court vacated the March 2022 Board decision, in relevant part, and remanded the matter for further actions consistent with the terms of the JMPR. With respect to the foregoing, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.800(d); 38 U.S.C. § 7112. The Board finds that the AOJ did not substantially comply with the July 2021 Board remand directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). Entitlement to service connection for a GI disorder is remanded. The Veteran contends that her GI disorder is secondary to her service-connected psychiatric disability and associated medication, to include obesity serving as an intermediate step. Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). Put another way, secondary service connection requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Additionally, obesity may be an 'intermediate step' between a service-connected disability and a claimed disability that may be otherwise service connected on a secondary basis. See Walsh v. Wilkie, 32 Vet. App. 300, 303 (2020); VAOPGCPREC 1-2017 (Jan. 6, 2017). When adjudicating a claim for secondary service connection with obesity as an intermediate step, the Board must answer (1) whether the service-connected condition caused the veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing the disability for which secondary service connection is sought; and (3) whether the condition for which secondary service connection is sought would not have occurred but for the obesity caused by the service-connected disability. Id at 303-4. This inquiry extends both to causation and to aggravation. Id. at 305. The Board finds that the first and second elements of secondary service connection are met. First, the evidence shows where the Veteran was diagnosed with GERD, hiatal hernia, and gastritis. See June 1998, March 2013, April 2013 Private Treatment Records. Second, the Veteran has been service connected for a psychiatric disorder since September 2003. Thus, the issues for the Board are whether the Veteran's GI disorder is related to her (1) service-connected psychiatric disability and associated medication, or (2) obesity, insofar as it may have served as a determinative intermediate step between the two. The Board finds that a remand is necessary to enforce compliance and to provide the Veteran with an adequate VA medical opinion before it can render a fully informed decision on the issues based on the following. When the Secretary undertakes to provide a veteran with a VA medical examination or obtain an opinion, he must ensure that the examination or opinion provided is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Of particular relevance here, a medical examination or opinion that fails to address whether a service-connected disability aggravated the claimed disability is inadequate to inform the Board on the issue of secondary service connection. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Garner v. Tran, 33 Vet. App. 241, 249-50 (2021). Here, pursuant to the July 2021 Board remand, the Veteran was afforded an October 2021 VA medical opinion to address the nature and etiology of her GI disorder, to include as secondary to her service-connected psychiatric disability and associated medication. The records reviewer concluded that a nexus had not been established. The rationale is best summarized as follows. The Veteran was diagnosed in June 1988 with a tiny intermittent sliding hiatal hernia, mild gastroesophageal reflux disease, and mild gastritis. This was two years post-service and therefore intercurrent injury or disease cannot be ruled out as an etiology. There was no medical evidence presented to support the conclusion the Veteran's psychiatric condition, or medications for used for treatment, were the cause of her gastrointestinal conditions. The medical literature did not support these as a cause. See October 2021 VA Opinion. The Board finds that the October 2021 opinion provided no insight into the relevant inquiry, which is whether the Veteran's service-connected psychiatric disability, to include medication used for treatment, aggravated any functional impairment associated with her GI disorder. See El-Amin, 26 Vet. App. at 140. Instead, the records reviewer used the same rationale for the aggravation opinion as was used for the direct service connection opinion, but that rationale does not adequately address the aggravation issue. As such, the Board finds that the October 2021 VA opinion did not substantially comply with the Board's July 2021 remand directives. Additionally, the Veteran asserts that a January 2020 VA examiner acknowledged that the medication used to treat her service-connected psychiatric disability (Aripiprazole) could cause weight gain, which could in turn, increase GERD symptoms. Further, the Board notes that the September 2020 VA examiner concluded that GERD is likely due to a combination of hiatal hernia and morbid obesity as both conditions commonly result in GERD which is caused by incompetence of the lower esophageal sphincter. Specifically, he opined that obesity and hiatal hernia have a direct effect on rendering the sphincter ineffective in preventing the backflow of acidic juices from the stomach into the duodenum. Compare January 2020 Medical Opinion with September 2020 VA Addendum Opinion. However, the October 2021 records reviewer did not address whether obesity may serve as a substantial intermediate step in the causal chain between the Veteran's psychiatric disability treated with Aripiprazole and her GI disorder. See Walsh, 32 Vet. App. at 303-305. In this regard, the Board finds the October 2021 VA opinion inadequate. Based on the foregoing, the October 2021 VA opinion did not substantially comply with the Board's July 2021 remand directives. Consequently, the Board cannot make a fully-informed decision on the issue of secondary service connection because no VA examiner has provided an adequate opinion on the issue. Accordingly, a remand is necessary to enforce compliance and provide the Veteran with a new VA medical opinion responsive to the foregoing. The matters are REMANDED for the following action: 1. Obtain an addendum opinion to determine the nature and etiology of the Veteran's GI disorder. The examiner must review the claims file including a copy of this remand. The examiner is asked to provide a response to the following: (a.) Is the Veteran's GI disorder at least as likely as not (likelihood is at least approximately balanced or nearly equal) proximately due to her service-connected disabilities, to include medication used for treatment? (b.) Is her GI disorder at least as likely as not (likelihood is at least approximately balanced or nearly equal) aggravated, i.e., worsened beyond its natural progression, by her service-connected disabilities? (c.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal) that her service-connected disabilities, including medication used for treatment (i.) caused her to become obese or (ii.) aggravated her obesity? Both causation and aggravation, regardless of its permanence unless permanence is a significant matter for consideration, must be addressed. If so, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal) that the obesity or aggravation of obesity was a substantial factor in causing her current GI disorder? Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal) that her GI disorder would not have occurred but for the obesity caused or aggravated by her service-connected disabilities? In providing the nexus opinion for obesity, the examiner must specifically address the following: Whether the medication used to treat her service-connected psychiatric disability (Aripiprazole) could cause weight gain, which could in turn, increase GERD symptoms. Obesity as a risk factor for her hiatal hernia as noted in the October 2021 VA medical opinion. The September 2020 VA examiner's opinion that GERD is likely due to a combination of hiatal hernia and morbid obesity. The impact of her service-connected disabilities on her level of physical activity. Provide a rationale to support the opinions. Cory M. Picton Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. P. Skinner, Associate 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.