INTERVERTEBRAL DISC SYNDROME

Summary

The veteran, who served on active duty in the Army from October 2001 to November 2002, February 2003 to February 2004, and February 2008 to February 2010, with additional Army Reserve service, appeals the denial of service connection for a low back disability, acid reflux, and migraines. The Board granted service connection for a low back disability, finding that the evidence, including service treatment records and a buddy statement from a fellow service member, established an in-service incurrence and continuity of symptoms. The Board also granted service connection for acid reflux, finding a plausible link between the Veteran's GERD symptoms, which began during his 2003-2004 deployments to Iraq and Kuwait, and his stressful service, despite conflicting VA medical opinions. The claim for migraines was remanded. The Board found the January 2024 private medical opinion from Dr. ML regarding migraines to be conclusory and not probative. The VA examiner's March 2024 opinion found no causal link between PTSD and migraines, but the Board noted the examiner failed to address secondary aggravation. Additionally, the July 2024 VA examination was deemed inadequate as it did not properly address the Veteran's diagnosed migraines or the potential secondary relationships. The case was remanded for new VA opinions on the etiology and aggravation of migraines by PTSD, tinnitus, allergic rhinitis, and toxic exposures.

Rationale

Favorable finding of current disability from May 2024 decision.; In-service incurrence established by July 2018 muscle spasm and January 2019 dorsalgia diagnosis.; Buddy statement from PC corroborated chronic low back pain impacting job duties.; Continuity of symptomatology supported by post-service treatment records.; VA nexus opinion finding no link was factually inaccurate due to service records showing complaints.

Full Decision Text

Citation Nr: A26001758
Decision Date: 01/08/26	Archive Date: 01/08/26

DOCKET NO. 240730-460617
DATE: January 8, 2026

ORDER

Entitlement to service connection for a low back disability is granted.

Entitlement to service connection for acid reflux is granted.

REMANDED 

Entitlement to service connection for migraines is remanded.

FINDINGS OF FACT

1. The evidence probatively establishes that the Veteran's low back disability was incurred during his active service. 

2. The evidence probatively establishes that the Veteran's acid reflux began during his active service.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a low back disability have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for entitlement to service connection for acid reflux have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on DD Form 214-verified active duty from October 2001 to November 2002, from February 2003 to February 2004, and from February 2008 to February 2010.  The Veteran has additional service in the Army Reserve beginning in March 2001, as discussed below.

In the July 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Board of Veterans' Appeals' (Board) Direct Review docket.

In this VA Form 10182, the Veteran referenced a July 2021 rating decision's denial of service connection for a low back disability and acid reflux.  As the VA Form 10182 was received more than one year after the issuance of this rating decision, it is untimely received, and the appeal of this rating decision is invalid.

As to the claim seeking entitlement to service connection for migraines, the Board may only consider the evidence of record at the time of issuance of the July 25, 2024 agency of original jurisdiction (AOJ) decision on appeal.  38 C.F.R. § 20.301.  Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board.  38 C.F.R. §§ 20.300, 20.301, 20.801. 

As to the claim seeking entitlement to service connection for acid reflux, the Board may only consider the evidence of record at the time of issuance of the July 10, 2024 AOJ decision on appeal.  38 C.F.R. § 20.301.  Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board.  38 C.F.R. §§ 20.300, 20.301, 20.801. 

As to the claim seeking entitlement to service connection for a low back disability, the Veteran indicated that he was appealing December 2023 and May 2024 rating decisions.  The AOJ determined that new and relevant evidence had been received and readjudicated the claim in the May 2024 rating decision.  Therefore, it is favorable to consider the May 2024 rating decision as the one on appeal, as this allows the Board to consider the most expansive evidentiary record.  This determination is not inconsistent with the United States Court of Appeals for Veterans Claims' (Court) holding in Terry v. McDonough, 37 Vet. App. 1 (2023).  Consequently, the Board may only consider the evidence of record at the time of issuance of the May 4, 2024 AOJ decision on appeal.  38 C.F.R. § 20.301.  Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board.  38 C.F.R. §§ 20.300, 20.301, 20.801. 

The Board has considered the September 24, 2025 correspondence to the limited extent that it contains argument.  See Harvey v. Shulkin, 30 Vet. App. 10, 16-17 (2018) (recognizing the distinction between argument on behalf of a claimant and evidence).  Any evidence therein has not been considered, as it was received outside of an eligible evidentiary window.  The lay statements and medical opinion of Dr. ML received in September 2025 have only been considered because they are duplicates of the copies received in March 2024 during the open evidence window.  

As to the claims adjudicated below,
20.300, 20.301, 20.801. 

The Board has considered the September 24, 2025 correspondence to the limited extent that it contains argument.  See Harvey v. Shulkin, 30 Vet. App. 10, 16-17 (2018) (recognizing the distinction between argument on behalf of a claimant and evidence).  Any evidence therein has not been considered, as it was received outside of an eligible evidentiary window.  The lay statements and medical opinion of Dr. ML received in September 2025 have only been considered because they are duplicates of the copies received in March 2024 during the open evidence window.  

As to the claims adjudicated below, if the Veteran would like the United States Department of Veterans Affairs (VA) to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence.  38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision.  However, because the Board is remanding the claim seeking entitlement to service connection for migraines, any evidence the Board could not consider will be considered by the AOJ in the lower-level adjudication of the claim.  38 C.F.R. § 3.103(c)(2)(ii). 

In September 2024, the Board received a request from the Veteran's representative to withdraw from the case.  The withdrawal of services by a representative is governed by 38 C.F.R § 20.6, which provides that after an appeal to the Board has been filed, a representative may not withdraw services unless good cause is shown on motion.  The motion must be in writing, and must include the name of the Veteran, the name of the claimant or appellant if other than the Veteran, the applicable VA file number, and the reason why withdrawal should be permitted, and a signed statement certifying that a copy of the motion was sent by first-class mail, postage prepaid, to the Appellant, setting forth the address to which the copy was mailed.  38 C.F.R. § 20.6(a)(2).

The Veteran's representative requested to withdraw their services because the Veteran did not seek consultation from the representative and chose to bypass the representative by independently filing the Board appeal.  This is a good cause explanation for the withdrawal of services as the Veteran failed to cooperate with proper preparation and presentation of the appeal, which is an express form of good cause listed in the regulation.  38 C.F.R. § 20.6(a)(2).  However, the Board must deny the representative's request for withdrawal based on the representative's failure to adhere to the notice requirements in 38 C.F.R. § 20.6(a)(2).  In the September 2024 letter, the representative indicated that the Veteran "has been advised of our actions [to withdraw]," but the representative's letter did not contain "a signed statement certifying that a copy of the motion was sent by first-class mail, postage prepaid, to the Appellant, setting forth the address to which the copy was mailed."  As such, the evidence does not establish that the Veteran was apprised of the representative's intent to withdrawal from representation in compliance with 38 C.F.R. § 20.6, and on this basis, the representative's request must be denied.   

In the September 2024 letter, the Veteran's representative requested that the "Board consider any new evidence received, along with the evidence of record and tender a decision on [his] Appeal as soon as possible."  The Board cannot consider any new evidence received in September 2024 and must adhere to the evidence window provided in 38 C.F.R. § 20.301.  

Under 38 U.S.C. § 7104, Board decisions must be based on the entire record in the proceeding and upon consideration of all evidence and material of record and applicable provisions of law and regulation.  The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran.  Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000).  The Board must review the entire record but does not have to discuss each piece of evidence.  Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000).  The analysis below focuses on the most salient and relevant evidence within the period on review and on what this evidence shows, or fails to show, on the
 based on the entire record in the proceeding and upon consideration of all evidence and material of record and applicable provisions of law and regulation.  The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran.  Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000).  The Board must review the entire record but does not have to discuss each piece of evidence.  Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000).  The analysis below focuses on the most salient and relevant evidence within the period on review and on what this evidence shows, or fails to show, on the claims.  The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein.  See Timberlake, supra.

Service Connection

Service connection will be granted if it is shown that a veteran has a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty, in the active military, naval, air, or space service.  38?U.S.C. §?1110; 38?C.F.R. §?3.303.

Generally, to establish service connection, a veteran must show: (1) a current disability; (2) an in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred during service, the so-called "nexus" requirement.  See 38 U.S.C. § 1110; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  All elements must be satisfied before service connection may be achieved.  

Additionally, service connection may be achieved if any applicable presumptive service connection regulations apply to the Veteran's circumstances or when a claimed disability is shown to be proximately due to, the result of, or aggravated by a service-connected disability.

In April 2023, the Veteran submitted argument alleging that he had additional active service from July 24, 2017 to September 30, 2019.  In support of this argument, he submitted orders indicating that he was ordered to Active Duty Operational Support - Reserve Component (ADOS-RC) for (i) a duty period of 68 days from July 24, 2017 to September 30, 2017 with the stated purpose as "TRST-ADOS-COMMAND & STAFF SUPV SUPPORT...G1 SUPPORT;" (ii) a duty period of 365 days from October 1, 2017 to September 30, 2018 with the stated purpose as "PSRA-CMD & STAFF S - ADOS...G1 SUPPORT;" and (iii) a duty period of 365 days from October 1, 2018 to September 30, 2019 with the stated purpose as "PRSA - PLANNING SPT ADOS...G1 SUPPORT."  All of the orders identified 10 U.S.C. § 12301(d) as the appointment authority.

For the purpose of education benefits under 38 U.S.C. Chapter 33, "[i]n the case of members of the reserve components of the Armed Forces, service on active duty under a call or order to active duty under section 688, 12301(a), 12301(d), 12301(g), 12301(h), 12302, 12304, 12304a, or 12304b of title 10 or section 712 1 of title 14" qualifies as "active duty."  38 U.S.C. § 3301(1)(B) (emphasis added).  Resolving reasonable doubt in the Veteran's favor, the Board finds this definition also applies to the term "active duty" as used in the laws governing entitlement to VA compensation benefits under 38 U.S.C. Chapter 1 and 11.  See Gazelle v. McDonald, 27 Vet. App. 461, 464 (2016) ("[s]tatutes must be considered as a whole and in the context of the surrounding statutory scheme."); see also United States Nat'l Bank of Oregon v. Independent Ins. Agents of Am., Inc., 508 U.S. 439, 455, 113 S. Ct. 2173, 124 L. Ed. 2d 402 (1993) (quoting United States v. Heirs of Boisdore, 49 U.S. (8 How.) 113, 122, 12 L. Ed. 1009, (
.C. Chapter 1 and 11.  See Gazelle v. McDonald, 27 Vet. App. 461, 464 (2016) ("[s]tatutes must be considered as a whole and in the context of the surrounding statutory scheme."); see also United States Nat'l Bank of Oregon v. Independent Ins. Agents of Am., Inc., 508 U.S. 439, 455, 113 S. Ct. 2173, 124 L. Ed. 2d 402 (1993) (quoting United States v. Heirs of Boisdore, 49 U.S. (8 How.) 113, 122, 12 L. Ed. 1009, (1849)) (The Supreme Court cautioned that "[i]n expounding a statute, we must not be guided by a single sentence or member of a sentence, but [should] look to the provisions of the whole law, and to its object and policy.").

In assessing whether these periods of ADOS-RC qualify as active service, the Board finds provisions of VA's Adjudication Procedure Manual (M21-1) to be of particular relevance.  The M21-1 states that "duties performed under the ADSW [Active Duty for Special Work] program may be for operational, support, or training purposes."  If the duty was for the purpose of receiving training, it is not considered active duty.  All other duties performed under the ADSW program are considered active duty.  See M21-1, Part VI, Subpart ii, Chapter 3, Section A.4.c. (last accessed Dec. 3, 2025); see also VAOPGCPREC 25-90 (July 17, 1990) (holding that an individual serving as an instructor during a training period, rather than a trainee, was not performing active duty for training under the Department of Defense (DOD) definition of the term and was serving on "active duty").  

The Board further notes that "[t]he term ADOS Reserve Component (ADOS-RC) replaces RC-funded, voluntary active duty formerly known as Active Duty for Special Work (ADSW)."  See Department of the Army Office of the Assistant Secretary, Manpower and Reserve Affairs Memorandum for Deputy Chief of Staff G-1, G-3, (February 21, 2008) (regarding the "Policy for Management of Reserve Component Soldiers on Active Duty for Operational Support").  Thus, the M21-1's reference to ADSW refers to ADOS-RC service.  

The evidence establishes that the Veteran's ADOS-RC service from July 24, 2017 to September 30, 2019 was performed for support services, as G1 Support was noted as the stated purpose.  The G1 "is responsible for the execution of assigned functions and the achievement of missions in support of the Secretary of the Army, Chief of Staff of the Army and the Assistant Secretary of the Army (Manpower & Reserve Affairs)" and "develops and implements effective policy, identifies methods of execution of assigned functions, and leads programs that build sustained personnel readiness."  See G-1, https://www.army.mil/g-1 (last accessed Dec. 3, 2025).  G1 Support was consistent with the Veteran's reserve duties as a senior human resource noncommissioned officer with the United States Army Reserve Legal Command.  See e.g., 2018-2019 NCO Evaluation Report.  The Veteran's ADOS-RC service was not performed for training purposes and thus, it qualifies as active service pursuant to the M21-1 guidance.  

Although the M21-1 is not binding on the Board, the Board must address relevant provisions of the M21-1 and conduct an independent analysis before determining whether the provisions may be relied upon as a factor to support its decision.  See Overton v. Wilkie, 30 Vet. App. 257 (2018); Healey v. McDonough, 33 Vet. App. 312 (2021).  The Board finds the M21-1 provisions highly instructive in the present case, and given that they are favorable to the Veteran's circumstances, the Board accepts them as appropriate guidance.  Consistent with the above analysis, the Board concludes that the Veteran's ADOS-RC service from July 24, 2017 to September 30, 2019 qualifies as active service for VA compensation purposes.  

1. Entitlement to service connection for a low back disability is granted. 

The Veteran seeks entitlement to service connection for a low back disability.  He claims this disability developed as a result of years of wearing body armor during guard duty and physical training.  See March 2021 VA Form 21-526EZ.

In
  The Board finds the M21-1 provisions highly instructive in the present case, and given that they are favorable to the Veteran's circumstances, the Board accepts them as appropriate guidance.  Consistent with the above analysis, the Board concludes that the Veteran's ADOS-RC service from July 24, 2017 to September 30, 2019 qualifies as active service for VA compensation purposes.  

1. Entitlement to service connection for a low back disability is granted. 

The Veteran seeks entitlement to service connection for a low back disability.  He claims this disability developed as a result of years of wearing body armor during guard duty and physical training.  See March 2021 VA Form 21-526EZ.

In the May 2024 decision, the AOJ issued the favorable finding that the Veteran was diagnosed with a lumbar strain at the December 2023 VA examination.  The Board is bound by this favorable finding pursuant to 38 C.F.R. § 3.104(c), and the current disability element of the Veteran's service connection claim has been met.  

While the Veteran's lay reports have varied about when his low back pain originated, with reports from a March 2023 VA treatment record, the December 2023 VA examination, the April 2021 VA examination, and January 2019 physical training records placing the onset of his condition in 2003, 2004, 2006, and 2011 respectively, the evidence first shows clear cut evidence of a low back condition in July 2018, where the Veteran was assessed with muscle spasm of the back.  In December 2018, the Veteran was seen for low back pain for the past year.  In January 2019, he was seen for a follow-up visit for low back pain for the past year and he was diagnosed with dorsalgia.  

The presence of chronic low back pain during this time period is further corroborated by the buddy statement received in March 2024 from PC.  The statement from PC indicates that he served with the Veteran from July 2017 to September 2019 during the Veteran's active duty tour at the United States Army Legal Command.  PC recalled that the Veteran was experiencing chronic low back pain which impacted his ability to perform certain job duties and resulted in absences from work.  The Veteran's service personnel records reflect that PC served as the Veteran's performance evaluation rater during his ADOS-RC active duty service, as thus, he is qualified to comment on the Veteran's job performance issues during this time period.  The reports of PC are competent, credible, and consistent with the medical evidence of record.  The Veteran' service treatment records place the first clinically identifiable evidence of a low back disability during the Veteran's ADOS-RC active duty service, as corroborated by the lay reports of PC, and this evidence is sufficient to satisfy the in-service incurrence element of the Veteran's service connection claim. 

The Veteran has alleged continuity of symptomatology since his in-service incurrence of low back pain.  See e.g., September 2025 argument.  The Veteran is competent to report symptoms felt through the senses and through individual perception, and the Board finds these reports to be credible.  See Layno v. Brown, 6 Vet. App. 465, 469-471 (1994).  The Veteran's post-service treatment records document chronic and continuous complaints and treatment for low back pain following his release from ADOS-RC active service.  These lay reports and medical records support the contention that the Veteran has experienced a low back disability continuously since separation from his last period of active service and are sufficient to satisfy the medical nexus element of the Veteran's service connection claim.  See 38 C.F.R. § 3.303(d) ("Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service."). 

The Board notes that the electronic claims file contains a December 2023 VA medical nexus opinion where a VA examiner declined to link the Veteran's low back disability to his active service.  The VA examiner's rationale was premised on the lack of objective evidence of a back condition during the Veteran's active duty service based on silence in the service treatment records.  This conclusion is factually inaccurate, as the evidence verifies low back complaints and diagnosis during the Veteran's ADOS-RC service.  As such, this VA medical nexus opinion is not probative in this appeal.  See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value").

The Veteran has also submitted a private medical opinion authored by Dr. ML in January 2024, which opined that the Veteran's low back disability was
 service.  The VA examiner's rationale was premised on the lack of objective evidence of a back condition during the Veteran's active duty service based on silence in the service treatment records.  This conclusion is factually inaccurate, as the evidence verifies low back complaints and diagnosis during the Veteran's ADOS-RC service.  As such, this VA medical nexus opinion is not probative in this appeal.  See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value").

The Veteran has also submitted a private medical opinion authored by Dr. ML in January 2024, which opined that the Veteran's low back disability was aggravated by his service-connected disabilities and/or directly connected to service due to the onset of symptoms in service.  Dr. ML cited literature indicating that posttraumatic stress disorder (PTSD) symptoms are associated with an increased incidence of chronic back pain and may be a modifiable risk factor for the prevention of chronic back pain but did not explain how PTSD causes or aggravates a lumbar strain.  Dr. ML cited no literature or rationale explaining how any of the Veteran's other service-connected disabilities caused or aggravated his low back disability.  Similarly, Dr. ML provided no explanation as to why the Veteran's current low back disability has a relationship with his in-service symptoms.  Simply stated, Dr. ML's medical opinion was wholly conclusory and bereft of reasoned medical judgment.  None of the medical opinions proffered were supported by explanatory rationales, and as such, Dr. ML's medical opinion is not probative in this appeal and holds no evidentiary weight.  See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 

Despite the inadequate nature of the December 2023 VA medical nexus opinion and the January 2024 private medical opinion, the evidence establishes that the requisite elements of direct service connection have been satisfactorily met.  Consequently, the Board shall grant the appeal seeking entitlement to service connection for a low back disability.  

2. Entitlement to service connection for acid reflux is granted. 

The Veteran seeks entitlement to service connection for acid reflux, claiming it was incurred during his active duty service.  Alternatively, he has asserted that this disability developed secondary to his service-connected PTSD under the provisions of 38 C.F.R. § 3.310.  See October 2022 VA Form 21-526EZ; December 2023 VA Form 21-10210.

The current disability element of a service connection claim is not in dispute.  In the July 10, 2024 rating decision, the AOJ issued the favorable finding that the Veteran was diagnosed with gastroesophageal reflux disease (GERD) at an April 2024 VA examination.  The Board is bound by this favorable finding pursuant to 38 C.F.R. § 3.104(c), and the current disability element has been satisfied. 

The Veteran has asserted that the exposure to consistently stressful environments, including his 2003-2004 deployment to Kuwait and Iraq, resulted in the development and worsening of GERD.  He stated that since 2003, he has experienced chronic symptoms of pain, vomiting, and uncontrolled weight stability.  See December 2023 VA Form 21-10210.  In February 2021 VA treatment records, and at the April 2021 and April 2024 VA examinations, the Veteran placed the onset of his GERD symptoms in 2004.  In March 2023 VA treatment records, the Veteran reported the presence of reflux for many years.  In the March 2024 VA Form 21-526EZ, the Veteran reported that his GERD symptoms began during his service in 2003 with episodes of abdominal pain and vomiting.  The Veteran has been shown to be a reliable medical historian, and his lay reports are both competent and credible and serve as persuasive evidence in support of the claim. 

The record reflects that the Veteran served in Iraq from April 2003 to August 2003 and in Kuwait in January 2004.  As such, the Veteran is presumed to have been exposed to burn pits and other environmental toxins during this service.  38 U.S.C. §§ 1119.

The Veteran's records do not document complaints, findings, or diagnosis of GERD or related symptoms in 2003 or 2004 during his periods of overseas deployment.  The earliest documented evidence of heartburn appears in medical records dated September 2006; however, this notation is not identified as the initial onset of the condition.  Instead, heartburn is mentioned in the prior medical history section, indicating the presence of this symptom before the record date.  Given that these 2006 records are relatively close to his deployment periods
 in Kuwait in January 2004.  As such, the Veteran is presumed to have been exposed to burn pits and other environmental toxins during this service.  38 U.S.C. §§ 1119.

The Veteran's records do not document complaints, findings, or diagnosis of GERD or related symptoms in 2003 or 2004 during his periods of overseas deployment.  The earliest documented evidence of heartburn appears in medical records dated September 2006; however, this notation is not identified as the initial onset of the condition.  Instead, heartburn is mentioned in the prior medical history section, indicating the presence of this symptom before the record date.  Given that these 2006 records are relatively close to his deployment periods from April 2003 to August 2003 in Iraq and his service in Kuwait in January 2004, it is reasonable to interpret the September 2006 medical records as consistent with the Veteran's accounts of experiencing heartburn beginning during his deployments in 2003/2004.  This suggests a plausible link between his in-service experiences and the onset of his GERD symptoms.

The records further establish the presence of GERD during the Veteran's ADOS-RC period of active service.  Treatment records from December 2018 identified the Veteran's reports of worsening heartburn in the preceding 6 months managed with over the counter acid blocking medication.  The above evidence is sufficient to conclude that the Veteran experienced GERD and related symptoms of heartburn coincident with his periods of active service.  

In support of this claim, the Veteran submitted buddy statements in March 2024 authored by his spouse, JH, and his service mate, DR, which noted that the Veteran experienced chronic symptoms of acid reflux.  The statement of JH does not indicate when the Veteran's GERD symptoms began, but she theorized that the Veteran's PTSD exacerbated his symptoms.  JH is competent to report her personal observations and experiences, but she does not have the medical training, education, or expertise to competently opine on complex medical matters, such as whether the Veteran's PTSD has clinically aggravated his GERD beyond the condition's normal progression.  See Layno, 6 Vet. App. at 469-71; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 

The statement of DR contains his recollections of the Veteran navigating the difficulties of managing his GERD symptoms during the time they served together.  DR did not specifically identify when his service with the Veteran occurred, and thus, it is difficult to assess what time period DR was referencing in his lay reports.  He recalled sitting up late at night with the Veteran taking turns using anti-acid medication to qualm their GERD symptoms.  These lay statements are credible and competent, but their failure to identify the time period in question renders them of little probative value in this appeal. 

The record contains VA medical nexus opinions from April 2021 and July 2024, where the VA examiners declined to link the Veteran's GERD to his in-service toxic exposures.  The April 2021 VA examiner explained that GERD results from a weakness of the lower esophageal sphincter, which allows for acid to regurgitate into the esophagus, and there is no known Southwest Asia exposure event associated with the development of GERD.  The July 2024 VA examiner explained that the Veteran's risk factors of a smoking history and extra weight far outweigh his in-service toxic exposures as the likely cause of his GERD.  The VA examiner explained that carrying extra weight puts pressure on the stomach, leading to more stomach acid traveling into the esophagus resulting in heartburn and GERD symptoms, and that smoking weakens the esophageal sphincter, reducing its ability to keep stomach acid from entering the esophagus.  The Board finds these VA medical opinions to be thoughtfully explained and adequate to resolve the issue of whether the Veteran's disability is linked to his in-service toxic exposures.  

The July 2024 VA examiner provided a VA medical nexus opinion addressing the Veteran's contention that his GERD developed secondary to his PTSD.  The examiner explained that medical literature supports the theory that PTSD can lead to the development of acid reflux in the absence of other co-morbidities.  The VA examiner stated that stress can increase the likelihood of GERD symptoms making the esophagus more sensitive to acid.  Chronic stress and hyperarousal from trauma exposure can also trigger the sympathetic nervous system, which can lead to altered GI [gastrointestinal] motility and symptoms like pain and cramping.  However, the examiner noted that this was not the only factor at play in the Veteran's situation, as he had an overweight body mass index and a history of smoking, which as explained above,
 the Veteran's contention that his GERD developed secondary to his PTSD.  The examiner explained that medical literature supports the theory that PTSD can lead to the development of acid reflux in the absence of other co-morbidities.  The VA examiner stated that stress can increase the likelihood of GERD symptoms making the esophagus more sensitive to acid.  Chronic stress and hyperarousal from trauma exposure can also trigger the sympathetic nervous system, which can lead to altered GI [gastrointestinal] motility and symptoms like pain and cramping.  However, the examiner noted that this was not the only factor at play in the Veteran's situation, as he had an overweight body mass index and a history of smoking, which as explained above, plays a role in the pathogenesis of GERD.

While the July 2024 VA medical opinion weighs against the conclusion that the Veteran's PTSD played a role in the development of his GERD, it positively indicated that stressful environments could cause GERD symptoms and identified a scientifically plausible mechanism of action.  This medical rationale is consistent with the Veteran's competent and credible lay reports that his symptoms began in 2003/2004 while deployed in a stressful environment in the Southwest Asia theater of operations.  The Board finds it to be more than a coincidence that the Veteran's GERD symptoms first manifested during his stressful period of service in Iraq and Kuwait.  Viewing the July 2024 VA medical opinion in concert with his lay reports, the Board finds it to be probative and adequate to resolve the medical nexus issue.  While it is true that the Veteran was overweight in 2003/2004 just as he is today, he denied tobacco abuse around that time.  In the July 2024 opinion, the VA examiner stated that "it cannot be definitively stated that the veteran's PTSD [or period of stress] alone has caused acid reflux versus the extra weight as well as the smoking," and given this ambiguity, the Board finds it appropriate to resolve reasonable doubt in the Veteran's favor.  38 C.F.R. § 3.102.  

While the above analysis supports the award of service connection on a direct basis, the Board is compelled to address the January 2024 medical opinion of Dr. ML, which opined that the Veteran's GERD was related to the Veteran's service or developed secondary to all of the Veteran's service-connected disabilities, to specifically include PTSD and allergic rhinitis.  Dr. ML's statements that the Veteran's GERD is directly connected to his service through onset of his symptoms or developed secondary to the Veteran's service-connected disabilities are entirely conclusory and devoid of rationale.  

When Dr. ML addressed the relationship between the Veteran's GERD and his PTSD or allergic rhinitis, he merely cited medical literature showing a correlation or association between individuals with PTSD and/or allergic rhinitis and the development of GERD.  He also cited an article concluding that the use of nonsteroidal antiinflammatory medication or aspirin use serves as a risk factor for GERD symptoms but did not explain the relevance of this article.  Unlike the July 2024 VA examiner, Dr. ML did not identify any pathological mechanisms by which PTSD or allergic rhinitis can cause or aggravate GERD, and he did not explain what evidence was relied upon to conclude that these mechanisms actually occurred in the Veteran's circumstances.  Moreover, Dr. ML did not address the limitations or the conflicting findings in the medical literature cited.  For instance, the Gradus study cited was based on a cohort in Denmark, unrelated to the Veteran, and the Kung study stated that it did not consider confounding lifestyle factors, such as obesity and smoking, which are relevant to the Veteran's situation.  It appears that Dr. ML simply copied and pasted language from the abstracts of the cited studies without actually reading or addressing their methods, discussions, or analysis.  For these reasons, Dr. ML's medical opinion is not probative in this appeal and is assigned no evidentiary weight. 

Resolving reasonable doubt in the Veteran's favor, the evidence establishes a clinically diagnosed condition, credible lay evidence of in-service onset of symptoms in 2003/2004 while on deployment, corroborated by 2006 reports noting a history of GERD, and a plausible theory of medical nexus provided by the July 2024 VA examiner.  As the requisite elements of service connection have been satisfied, the Veteran's appeal seeking entitlement to service connection for acid reflux is granted.  

REASONS FOR REMAND

Pursuant to 38 C.F.R. § 20.802(a), the Board's authority to remand a claim is limited to instances requiring (1) correction of an error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A, if the error occurred prior to the date
 onset of symptoms in 2003/2004 while on deployment, corroborated by 2006 reports noting a history of GERD, and a plausible theory of medical nexus provided by the July 2024 VA examiner.  As the requisite elements of service connection have been satisfied, the Veteran's appeal seeking entitlement to service connection for acid reflux is granted.  

REASONS FOR REMAND

Pursuant to 38 C.F.R. § 20.802(a), the Board's authority to remand a claim is limited to instances requiring (1) correction of an error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A, if the error occurred prior to the date of the AOJ decision on appeal, or (2) the correction of any other error by the AOJ in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the Appellant's claim.

1. Entitlement to service connection for migraines is remanded. 

The Veteran seeks entitlement to service connection for migraines, primarily under the theory that his disability developed secondary to his service-connected PTSD and tinnitus.  See March 2024 VA Form 21-526EZ.  A January 2024 private medical opinion of Dr. ML has also raised alternative theories of entitlement, as addressed below. 

In March 2024, the Veteran submitted a buddy statement from AH, who is a friend the Veteran has known since high school.  AH discussed the Veteran's experience with headaches but his lay statement did not otherwise contain information necessary for substantiating the claim. 

The Veteran submitted a January 2024 private medical opinion from Dr. ML who diagnosed the Veteran with migraine headaches based on a telehealth visit and opined that the Veteran's headaches are directly connected to his active duty service due to the onset of symptoms in service.  However, the Veteran has never alleged that he experienced headaches during active service, and he told the July 2024 VA examiner that his headaches began in the summer of 2023.  In this regard, Dr. ML's medical opinion is not probative and holds no evidentiary weight.  See Reonal, 5 Vet. App. at 460-61.  

Dr. ML also opined that the Veteran's "service rated conditions are connected and have aggravated his migraines," but he only addressed the alleged relationship between the Veteran's migraines and his service-connected tinnitus, PTSD, and allergic rhinitis, as well as a generalized statement regarding chronic pain. 

As to the purported relationship between PTSD and tinnitus, Dr. ML cited literature showing that both migraine and PTSD are more prevalent in women than men.  However, male migraineurs may have even greater odds of suffering from PTSD than their female counterparts.  Additionally, the presence of PTSD in individuals with migraines is associated with greater headache-related disability compared to those without PTSD.  Furthermore, a population-based longitudinal study found that patients with PTSD have a higher risk of developing migraines, with the severity of PTSD symptoms potentially increasing the risk of migraines.  This explanation was based on theories of statistical correlation and did not address any biological mechanism by which PTSD can cause or aggravate migraines, and if one exists, what evidence shows the phenomenon occurred in the Veteran's specific case.  A correlation means there is an association between two variables but does not necessarily imply that one causes the other.  Dr. ML's medical opinion fails to acknowledge this distinction, and causation, not correlation, is required to support a secondary service connection claim.  For these reasons, the opinion of Dr. ML is not probative in this appeal and holds no evidentiary weight.  

Regarding the tinnitus and migraines, Dr. ML cited literature for the proposition that both conditions "may be linked by common pathophysiological mechanisms" based on principles of lateralization and temporality.  However, Dr. ML did not explain what these terms mean; he did not clearly identify the pathophysiological mechanism; and assuming one exists, he did not explain what evidence he relied upon to conclude the phenomenon actually existed in the Veteran's unique case.  As such, this medical opinion is not fully articulated and supported by sound reasoning, and it is entitled to no evidentiary weight. 

Next, Dr. ML addressed the alleged relationship between migraines and chronic pain, stating that chronic musculoskeletal pain has been found by one study to be 2 times more frequent in chronic migraine patients.  This statement does not explain, articulate, or otherwise indicate that migraines may be caused or aggravated by musculoskeletal pain.  As such, this medical opinion is irrelevant and does not reasonably raise the contention that the Veteran's migraines are secondary to any of his service-connected musculoskeletal conditions.  

Lastly, Dr. ML opined that
 phenomenon actually existed in the Veteran's unique case.  As such, this medical opinion is not fully articulated and supported by sound reasoning, and it is entitled to no evidentiary weight. 

Next, Dr. ML addressed the alleged relationship between migraines and chronic pain, stating that chronic musculoskeletal pain has been found by one study to be 2 times more frequent in chronic migraine patients.  This statement does not explain, articulate, or otherwise indicate that migraines may be caused or aggravated by musculoskeletal pain.  As such, this medical opinion is irrelevant and does not reasonably raise the contention that the Veteran's migraines are secondary to any of his service-connected musculoskeletal conditions.  

Lastly, Dr. ML opined that a correlation exists between allergic rhinitis and migraine without aura, and the correlation increases with age.  Again, Dr. ML's opinion is based on correlation and not causation, and as such, it lacks the degree of specificity and rationale needed to successfully substantiate a secondary service connection theory of entitlement.  As such, this medical opinion holds no evidentiary weight.  

In March 2024, a VA examiner issued a negative nexus opinion agreeing with Dr. ML that research shows a correlation between PTSD and migraines, but opining that she was unable to locate any medical research showing that PTSD causes the onset of a migraine condition, and as such, it was less likely than not that the Veteran's migraines developed as a result of the Veteran's PTSD.  The Board finds this VA medical nexus opinion to be adequate and sufficient to resolve the causation component of a secondary service connection claim.  Unlike Dr. ML, the VA examiner applied the correct legal standard and thoughtfully explained that she was unable to locate research establishing a causal relationship between PTSD and migraines.  However, a remand is still required, as during the predecisional period, the AOJ failed to obtain a VA medical nexus opinion addressing the principle of secondary aggravation.  38 C.F.R. § 20.802(a); see Atencio v. O'Rourke, 30 Vet. App. 74, 91 (2018) (causation and aggravation are independent concepts and should have separate findings and rationales). 

The Veteran attended a VA headaches examination in July 2024, where the VA examiner marked that the Veteran had not been diagnosed with a headache condition.  The examiner noted Dr. ML's diagnosis of headaches but stated it was based on a single one-time telehealth visit and there was a lack of substantiating evidence to confirm a diagnosis of migraine headaches.  The examiner stated the claims file was negative for evidence related to a confirmed diagnosis of migraines.  The examiner cited January 2024 VA treatment records documentation of headaches, but noted the clinician was unable to distinguish between tension or migraine headaches.  The examiner declined to answer the questions on whether the Veteran's claimed migraines were due to his in-service toxic exposures or secondary to his PTSD, repeatedly asserting that he did not have a migraine diagnosis and his symptoms were subjective in nature. 

VA addendum medical opinions from the July 2024 VA examiner were obtained on July 17, 2024 and July 23, 2024.  In the July 17th opinion, the examiner stated there was no medical or scientific literature indicating a causal relationship between the Veteran's migraines and his toxic exposures, and she opined that she agreed with the March 2024 VA examiner that no scientific research established a causal connection between PTSD and migraines.  The examiner did not address the principle of secondary aggravation.  In the July 23rd opinion, the examiner reiterated her belief that the Veteran did not have a diagnosis of migraine headaches based on the lack of records showing ongoing treatment for a migraine headache disability.

In July 2024, the Veteran called VA and challenged the adequacy of the July 2024 VA examination, arguing that the examiner's examination was cursory, lasted about 15 minutes, and the examiner closed the computer in the middle of the assessment, walked out, and stated the examination was over.  He believed the examination was inadequate.  The Board agrees.  The VA examiner did not offer a rational explanation for dismissing Dr. ML's diagnosis of migraine headaches.  Furthermore, the assertion that the Veteran's headaches are subjective in nature is inherently flawed, as headaches are a fundamentally subjective medical condition.  The diagnosis of headaches primarily depends on the individual's self-report of symptoms.  The requirement for a current disability is satisfied if there is evidence of the disability at any time close to or during the pendency of the claim, and Dr. ML's diagnosis met this requirement, and the July 2024 VA examiner did not provide an explanation coherently refuting his diagnosis.  McClain v. Nicholson, 21 Vet. App. 319 (200
 was inadequate.  The Board agrees.  The VA examiner did not offer a rational explanation for dismissing Dr. ML's diagnosis of migraine headaches.  Furthermore, the assertion that the Veteran's headaches are subjective in nature is inherently flawed, as headaches are a fundamentally subjective medical condition.  The diagnosis of headaches primarily depends on the individual's self-report of symptoms.  The requirement for a current disability is satisfied if there is evidence of the disability at any time close to or during the pendency of the claim, and Dr. ML's diagnosis met this requirement, and the July 2024 VA examiner did not provide an explanation coherently refuting his diagnosis.  McClain v. Nicholson, 21 Vet. App. 319 (2007).  The above evidentiary issues have called into question the qualifications and reliability of the VA examiner's assessment and medical opinion, and as such, the July 2024 VA examination reports are not probative in this appeal. 

As noted above, the claim must be remanded to correct a predecisional error in the AOJ's failure to obtain an opinion addressing whether the Veteran's migraines have been aggravated by his service-connected PTSD.  As the July 2024 VA medical opinions have been determined to lack probative value, the AOJ also erred in failing to obtain an adequate opinion during the predecisional period addressing whether the Veteran's migraines are related to his in-service exposure to burn pits and other environmental toxins.  38 C.F.R. § 20.802(a).  Lastly, the January 2024 private medical opinion provided the requisite indication that the Veteran's headaches may be secondary to his service-connected tinnitus and allergic rhinitis.  See McLendon v. Nicholson, 20 Vet. App. 79, 84-86 (2006).  During the predecisional period, VA's duty to assist was triggered in this regard and the AOJ failed to obtain appropriate VA medical nexus opinions addressing these raised secondary service connection theories of entitlement, thereby warranting a remand for corrective action.  38 C.F.R. § 20.802(a).

The matter is REMANDED for the following action:

1. Obtain addendum VA medical opinions from an appropriate VA examiner regarding the nature and etiology of the Veteran's migraine headaches.  To the extent possible, these opinions should be obtained by a provider other than the nurse practitioner who conducted the July 2024 examination.  The need for an updated in-person VA examination shall be left to the discretion of the VA examiner.  Following a complete review of the electronic claims file, including a copy of this REMAND, the VA examiner is requested to address the following inquiries:

(a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's migraines have been aggravated (i.e., underwent any incremental increase in disability, regardless of its permanence) by the Veteran's service-connected PTSD?

(b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's migraines have been caused or aggravated (i.e., underwent any incremental increase in disability, regardless of its permanence) by the Veteran's service-connected tinnitus?

(c.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's migraines have been caused or aggravated (i.e., underwent any incremental increase in disability, regardless of its permanence) by the Veteran's service-connected allergic rhinitis?

For the opinions requested regarding secondary causation and aggravation, the VA examiner is directed to provide a rationale discussing causation and aggravation as two separate inquiries. 

(d.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that a nexus exists between the Veteran's migraines and his in-service exposure to burn pits and other environmental toxins?

2. The AOJ is requested to ensure that ALL VA medical opinions are supported by a complete explanatory rationale based on the VA examiners' medical expertise and clinical experience; established medical principles; and citations to the record, as appropriate.

 

 

Cynthia M. Bruce

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Galante, 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.