GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Summary

The veteran, who served from August 1968 to June 1970, appeals the denial of service connection for gastroesophageal reflux disease (GERD). The veteran claimed GERD was secondary to his service-connected anxiety disorder (claimed as PTSD) and/or NSAID treatment for his service-connected left knee arthroplasty. The Board reviewed the evidence, noting that the veteran's service treatment records did not reveal a diagnosis or treatment for GERD. VA treatment records from 2013 showed complaints of heartburn and dysphagia, which improved with Omeprazole, but no ongoing diagnosis or treatment for GERD was documented after July 2015. A December 2020 VA examination concluded the veteran did not have a current diagnosis of GERD, and the examiner's opinion regarding nexus was inadequate as it failed to acknowledge prior dyspepsia/dysphagia complaints. However, addendum VA medical opinions from May 2023 were deemed adequate, finding the GERD claim less likely than not proximately due to or the result of service-connected conditions, citing no objective evidence of GERD and noting the prior dyspepsia/dysphagia was acute and resolved. The Board found the probative evidence weighed persuasively against a current diagnosis of GERD, thus denying service connection. The veteran was advised on filing a Supplemental Claim for new evidence.

Rationale

No current diagnosis of GERD found in service treatment records.; VA treatment records showed acute dyspepsia/dysphagia resolved with medication.; VA examiner opined GERD was less likely than not related to service-connected knee disability due to lack of diagnosis and inconsistent symptoms.

Full Decision Text

Citation Nr: A25081262
Decision Date: 09/24/25	Archive Date: 09/24/25

DOCKET NO. 250812-574967
DATE: September 24, 2025

ORDER

Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied.

FINDINGS OF FACT

1. The evidence weighs persuasively against finding the Veteran has a current disability of GERD.

2. The Veteran does not currently have GERD.

CONCLUSION OF LAW

The criteria for entitlement to service connection for GERD have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty from August 1968 to June 1970.

This matter comes before the Board of Veterans' Appeals (Board) on appeal of an August 2024 rating decision issued by a Department of Veterans Affairs (VA) regional office, an agency of original jurisdiction (AOJ). That rating decision was issued in response to a May 2024 VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), which sought review of a May 2023 rating decision.

The Veteran timely initiated an appeal by submitting an August 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and elected the Direct Review docket. In view of the above, the Board may only consider the evidence of record that the AOJ was permitted to consider at the time it issued the decision on appeal (i.e., the evidence of record at the time the AOJ issued the May 2023 rating decision). 38?C.F.R. § 20.301. 

The Board did not consider evidence added to the claims file after the May 2023 rating decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify new evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (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. Wallin v. West, 11 Vet. App. 509 (1998). Any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disability, will be service connected. 38 C.F.R. § 3.310(b).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

GERD

The Veteran contends his GERD is secondary to his service-connected other specified anxiety disorder (claimed as PTSD) and/or his treatment with NSAID for his service-connected left knee arthroplasty. See October 2020 VA Form 21-526EZ, Application for Disability Compensation and
. § 3.310(b).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

GERD

The Veteran contends his GERD is secondary to his service-connected other specified anxiety disorder (claimed as PTSD) and/or his treatment with NSAID for his service-connected left knee arthroplasty. See October 2020 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. 

While the Veteran is competent to report observable symptoms, he is not competent to diagnose GERD. Layno v. Brown, 6 Vet. App. 465, 469 (1994). 

The Veteran's service treatment records (STRs) do not reveal treatment or a diagnosis of GERD.

The Veteran's VA treatment records note the Veteran complained of heartburn in February 2013 and took over-the-counter medication for 14 days that helped his symptoms. He was prescribed Omeprazole for dyspepsia and dysphagia. In April 2013, the Veteran's VA treatment records note his heartburn and dysphagia improved on Omeprazole and he was advised to continue the medication. His treatment records note he was taking Omeprazole in October 2013, July 2014, and July 2015. In January 2018, the Veteran reported no gastrointestinal symptoms. Throughout the remainder of the appeal period, the Veteran's VA treatment records reveal he consistently denied a change in appetite, dysphagia, heartburn, abdominal pain, or belching/gas.

In November 2021, the Veteran's VA treatment records note his medical provider's concerns the Veteran may have been taking 800mg of ibuprofen, in which case the provider noted Omeprazole would be recommended to lower the Veteran's gastrointestinal bleed risk. The Veteran confirmed he had not been using ibuprofen "for some time now" because he was aware of the effects it could have on his kidneys and gastrointestinal system. He reported he had been taking 640mg of Tylenol Arthritis every 8 hours for his left knee pain. The Veteran's treatment records do not show Omeprazole was prescribed to the Veteran after July 2015.

The Veteran underwent a VA examination in December 2020. The examiner determined the Veteran did not have a current diagnosis of GERD. The Veteran reported that he wakes up in the morning and is nauseated, feels bloated in the suprapubic region, and it hurts to urinate or have a bowel movement. The Veteran reported he has no substernal burning and has some difficulty swallowing. The examiner opined the Veteran's GERD was less likely than not proximately due to or the result of the Veteran's service-connected left knee disability because no diagnosis of GERD was rendered. The examiner noted the Veteran's history and medical records do not confirm a diagnosis of GERD and his symptoms are not consistent with GERD.

The December 2020 VA examiner failed to acknowledge the medical evidence showing dyspepsia and dysphagia in the Veteran's VA treatment records. Thus, the December 2020 VA examiner's nexus opinion is inadequate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion based upon an inaccurate factual premise has no probative value). Nevertheless, the examiner's assessment of whether the Veteran currently has the claimed disability is probative. The examiner acknowledged the Veteran's lay statements describing his current symptoms and explained that they are not consistent with GERD.

Addendum VA medical opinions were submitted in May 2023. The examiner opined the Veteran's GERD is less likely than not proximately due to or the result of his service-connected other specified anxiety disorder or his service-connected left total knee arthroplasty. The examiner noted there is no objective evidence of record for GERD. The examiner acknowledged the Veteran has a history for treatment for dyspepsia and dysphagia in July 2015 without a diagnosis of GERD. The examiner also noted the condition, including dyspepsia and dysphagia, was acute and resolved as evidenced by no ongoing complaint, treatment, or diagnosis and there is no chronicity of care.

The May 2023 VA addendum opinions are adequate and constitute highly probative evidence.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997). The probative evidence weighs persuasively against finding
 is no objective evidence of record for GERD. The examiner acknowledged the Veteran has a history for treatment for dyspepsia and dysphagia in July 2015 without a diagnosis of GERD. The examiner also noted the condition, including dyspepsia and dysphagia, was acute and resolved as evidenced by no ongoing complaint, treatment, or diagnosis and there is no chronicity of care.

The May 2023 VA addendum opinions are adequate and constitute highly probative evidence.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997). The probative evidence weighs persuasively against finding the Veteran has a current disability of GERD. In the absence of proof of a present disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 

For the above reasons, the evidence for and against the claim is neither evenly balanced, nor approximately so. Rather the probative evidence weighs persuasively against the claim and demonstrates the Veteran does not have a current diagnosis of GERD. The benefit of the doubt doctrine is therefore not for application and service connection for GERD is not warranted.

 

SHAUN S. SPERANZA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Magiros, Kristen N.

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.