Citation Nr: 23040586 Decision Date: 07/25/23 Archive Date: 07/25/23 DOCKET NO. 19-35 905 DATE: July 25, 2023 REMANDED Entitlement to service connection for gastroesophageal reflux disease ("GERD") is remanded. Entitlement to service connection for a heart disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1987 to September 1988. 1. GERD & 2. Heart disability The Board remanded the matter in March 2023. The Veteran is service connected for bipolar disorder, which has been claimed to cause the Veteran's heart disabilities and GERD. The service-connected bipolar disorder includes symptoms of anxiety and depression. See, e.g., June 2023 rating decision (citing an August 2018 VA examination). On the prior March 2023 Board remand, the Board requested an opinion regarding whether a heart disability or GERD was "proximately due to, or aggravated, i.e., worsened beyond its natural progression, by [the Veteran's] service-connected bipolar disorder." A VA examination dated in May 2023 noted the Veteran had arteriosclerotic heart disease (coronary artery disease) status-post percutaneous coronary intervention (PCI) with sten and stable angina. For coronary artery disease, a VA opinion was obtained and is dated in May 2023. Regarding a causal relationship, the opinion noted that coronary artery disease has strong risk factors of "diabetes, smoking, excessive alcohol intake, dyslipidemia, and hypertension," that the Veteran's chest pains first occurred after mental health treatment, and that "UpToDate failed on coronary heart disease failed to demonstrate bipolar disorder as a risk factor for Heart conditions." For whether there was a relationship between bipolar disorder and heart disabilities, the examiner cited a single article that was specifically about the risk of coronary heart disease in people with diabetes. An additional opinion that same month regarding aggravation also noted that "the medical literature reviewed failed to demonstrate a relationship" between the Veteran's heart disabilities and bipolar disorder. The examiner again cited the same single article regarding risk of coronary artery disease in people with diabetes. For GERD, a VA opinion dated in May 2023 noted there was "no data supporting a biological link between the two conditions." The examiner reported that the "medical literature from NIH- PubMed, reports many factors may contribute to the development of the disease. Among them, there are non-modifiable factors such as age, sex, or genetic factors and modifiable factors, e.g., lifestyle, diet, and excessive body weight." Further, the opinion states that "this examiner cannot correlate the relation based on my assessment (obesity), medical treatment record, and the peer-reviewed literature." Regarding aggravation, the examiner noted the record was silent for evidence of symptoms of GERD and that medical literature review "showed no biologic relationship" between GERD and bipolar disorder. However, the single article cited to support this statement notes that "role of lifestyle, diet[,] and eating habits as risk factors for GERD is not clearly understood, and the results of the available studies are often contradictory." Also in May 2023, the representative submitted medical literature regarding the matter. One article dated in 2010 noted a relationship between anxiety and coronary heart disease. This states that "early-onset anxiety but not depression is a risk factor for coronary heart disease" and "anxiety as diagnosed by experts . . . independently predicated subsequent C[oronary] h[eart] d[isease] events." A second article, dated in October 2018, noted that a study showed notable higher levels of anxiety and depression in people with GERD. For three of the four opinions provided (both VA opinions regarding the heart and the aggravation opinion for GERD), the VA opinions' rationale largely seems to consist of the fact that "the medical literature" failed to show a relationship and then cited a single source for each disability. The two sources cited do not appear to support the conclusions drawn. One article was limited to the relationship between diabetes and coronary heart disease and the other article noted that lifestyle risk factors for GERD are not clearly understood. The VA opinions are also unclear whether additional medical literature, not specifically cited or explained, showed a relationship was less likely (i.e., medical literature contained information showing that bipolar disorder is less likely to cause or aggravate heart disabilities or GERD) or whether medical literature addressing the matter does not exist. Additional opinions with supporting rationale are therefore necessary. The matters are REMANDED for the following action: 1. Obtain a VA opinion regarding the Veteran's heart disabilities. The examiner is asked the following: are the Veteran's heart disability or disabilities at least as likely as not (likelihood is at least approximately balanced or nearly equal) proximately due to, or aggravated (worsened beyond its natural progression) by service-connected bipolar disorder? The examiner should consider the May 2021 private examiner's opinion and the medical articles submitted in May 2023 by the Veteran's representative. Provide a rationale to support the opinion(s). The examiner should provide citations, links, or summaries of all relevant medical literature reviewed in providing the above opinions. If the examiner finds that medical literature does not support a finding that bipolar disorder is a risk factor for, or cause of, the Veteran's heart disability or disabilities, the examiner must state whether the medical literature specifically made such a finding (i.e., states bipolar disorder specifically is not, or is unlikely to be, a cause of a heart disability) and not whether medical literature reviewed simply did not discuss bipolar disorder. 2. Obtain a VA opinion regarding the Veteran's GERD. The examiner is asked the following: is GERD at least as likely as not (likelihood is at least approximately balanced or nearly equal) proximately due to, or aggravated by (worsened beyond natural progression), service-connected bipolar disorder? The examiner should consider the May 2021 private examiner's opinion and the medical articles submitted in May 2023 by the Veteran's representative. Provide a rationale to support the opinion(s). The examiner should provide citations, links, or summaries of all relevant medical literature reviewed in providing the above opinions. If the examiner finds that medical literature does not support a finding that bipolar disorder is a risk factor for, or a cause of, GERD, the examiner must state whether the medical literature specifically made such a finding (i.e., states bipolar disorder specifically is not, or is unlikely to be, a cause of GERD) and not whether medical literature reviewed simply did not discuss bipolar disorder. 3. After the above development has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and the representative a Supplemental Statement of the Case. If necessary, return the case to the Board for further appellate review. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Yoffe, 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.