HERNIA HIATAL

Summary

The Veteran served from September 1982 to September 2002. The Veteran appeals the denial of service connection for a hiatal hernia and seeks an increased rating for right and left knee degenerative joint disease with instability, cerebrovascular accident (CVA) with left upper extremity weakness, and left lower extremity weakness. The Board granted service connection for a hiatal hernia, finding it attributable to service. The Veteran reported ongoing stomach issues since service, with documented symptoms in service medical records and subsequent treatment from 2005 onwards, including a hiatal hernia diagnosis in 2016. While VA examiners provided negative opinions regarding the etiology of the hiatal hernia, the Board found they failed to adequately address the Veteran's in-service symptoms and the possibility of an underlying hiatal hernia. The Board found the Veteran's lay statements credible and undisputed, concluding the symptoms likely started in service and were later identified. The claims for increased ratings for the knees, CVA with left upper extremity weakness, and left lower extremity weakness were remanded. The remand instructions noted that the Board must discount beneficial medication effects when rating disabilities, as per Ingram v. Collins. The VA examinations for these conditions were inadequate, either failing to use the correct DBQ for nerve involvement or not properly discounting medication effects. The Board ordered additional VA examinations to properly assess the severity of these conditions and discount medication effects before readjudication.

Rationale

Credible lay statements of in-service symptoms; Symptoms documented in service medical records; Subsequent diagnosis of hiatal hernia; VA opinions failed to adequately address in-service symptoms

Full Decision Text

Citation Nr: 26004099
Decision Date: 04/02/26	Archive Date: 04/02/26

DOCKET NO. 16-30 968
DATE: April 2, 2026

ORDER

Entitlement to service connection for a hiatal hernia is granted.

REMANDED

Entitlement to a disability rating in excess of 10 percent from August 27, 2014, for right knee degenerative joint disease with instability (Diagnostic Code (DC) 5010-5257) is remanded.

Entitlement to a disability rating in excess of 10 percent from August 27, 2014, for left knee degenerative joint disease with instability (DC 5010-5257) is remanded.

Entitlement to a disability rating in excess of 10 percent prior to January 3, 2015, for cerebrovascular accident (CVA) with left upper extremity weakness is remanded.

Entitlement to a disability rating in excess of 20 percent after January 3, 2015, for CVA with left upper extremity weakness is remanded.

Entitlement to a disability rating in excess of 20 percent for weakness, left lower extremity, is remanded.

FINDING OF FACT

A hiatal hernia is attributable to service. 

CONCLUSION OF LAW

A hiatal hernia was incurred in service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from September 1982 to September 2002.

The Veteran appeared at a Board hearing in April 2022; a transcript is of record. With respect to the Board hearing, the undersigned Veterans Law Judge clarified the issues on appeal, identified potential evidentiary deficits, and clarified the type of evidence that would support the Veteran's claim. These actions complied with any duties owed during a hearing. 38 C.F.R. § 3.103.

Service Connection

Service connection may be established for disability resulting from personal injury or disease contracted in the line of duty in the active military, naval, air, or space service.  38 U.S.C. §§ 1110, 1131.

To establish a right to compensation for a present disability, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); see also Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed.  Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also 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. 38 C.F.R. § 3.303(d).  

In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience.  Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.  38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board
 knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value.  In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995).

For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts.  See Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107.  

1. Entitlement to service connection for a hiatal hernia is granted.

The Veteran reported during his April 2022 Board hearing that his ongoing stomach difficulties started in service, and he has had stomach problems since.

A March 1983 service medical record indicates the Veteran was seen for evaluation for eosinophilia, abdominal cramping, and bloating. Final diagnosis was eosinophilia, abdominal cramping, bloating, loose stools, etiology undetermined.

A report of medical examination dated in December 2001 noted abdominal pain in the past, no current problems.

On a June 2002 retirement Report of Medical History, the Veteran did not note any stomach problems. An undated Report of Medical Examination at separation contains a blank clinical evaluation in all areas, including abdomen and viscera (include hernia).

An August 2005 VA emergency department record states that the Veteran had pain in his chest. Diagnosis was listed as "likely GERD" and a medical professional prescribed omeprazole. 

The Veteran had treatment for ongoing stomach issues since 2005. See, e.g., August 2013 VA treatment record (noting stomach biopsy for chronic-active gastritis); January 2016 VA treatment record (stating the Veteran had gastrointestinal symptoms with abdominal bloating, nausea, with episodes of nocturnal reflux, uncomfortable pain in the abdomen, and small hard stools). 

During his April 2022 Board hearing, the Veteran reported he was treated with medication in service and continues to take medication. He reported that he had chronicity of care since service, with current symptoms of bleeding, sore stomach muscles, and stomach pain. 

An April 2024 VA examination report notes that the Veteran had hiatal hernia. The medical history notes onset date of "1983/1984" and:

[The] Veteran states that while in service he started to experience[] severe stomach pain and had a parasitic infection and was worked up for it and had a[n] endoscopy done for it and was treated. [The] Veteran states that his stomach continued to bother him on and off while in service and [he] continued to be seen for it.

Course since [o]nset:

Since separation form[sic] service he has continued to be seen for his stomach and has had other endoscopies and takes medication and also probiotics for it. Symptoms . . . are worse. His stomach [symptoms?] [are] . . . discomfort and sensitivity and tenderness. He avoids eating certain foods.

Current [t]reatment:

Omeprazole 40 Mg Probiotics QD[.]

The examiner noted current signs and symptoms of hiatal hernia were abdominal pain and nausea.

There are multiple VA opinions of record, all negative etiology. 

The most comprehensive is a November 2024 VA addendum opinion noting, in the relevant part, the following:   

The [V]eteran was seen for abdominal pain while in service and had a stool sample taken and a parasitic infection was ruled out. He continued to complain of abdominal pain and loose stools and had had an endoscopy
 are worse. His stomach [symptoms?] [are] . . . discomfort and sensitivity and tenderness. He avoids eating certain foods.

Current [t]reatment:

Omeprazole 40 Mg Probiotics QD[.]

The examiner noted current signs and symptoms of hiatal hernia were abdominal pain and nausea.

There are multiple VA opinions of record, all negative etiology. 

The most comprehensive is a November 2024 VA addendum opinion noting, in the relevant part, the following:   

The [V]eteran was seen for abdominal pain while in service and had a stool sample taken and a parasitic infection was ruled out. He continued to complain of abdominal pain and loose stools and had had an endoscopy, with a biopsy, along with an upper GI series and barium enema to rule out inflammatory bowel disease. . . . He had a stool sample taken to rule out parasites[,] which did rule out parasites. . . . The [V]eteran also stated that his stomach issues never went away and he takes Omeprazole for his stomach issues. There is no mention of the [V]eteran complaining of heart burn or indigestion while in service or having a hiatal hernia while in active service[.] [H]owever[,] on day of exam[ination], it showed that he had an endoscopy done dated 03/12/2016 which showed he had a hiatal hernia and shows he is currently taking Omeprazole. Omeprazole is used to help treat hiatal hernias along with avoiding eating certain foods . . . . 

The opinion states that active duty was less likely the cause of hiatal hernia, as "the literature does not show a causative link between a parasitic infection to a hiatal hernia." An April 2024 VA opinion likewise provides a negative opinion and notes that "the literature does not show a causative link between a parasitic infection to a hiatal hernia." 

A December 2024 VA opinion states that hiatal hernia was less likely due to eosinophilia, noted in 1983. No rationale was provided. 

An additional December 2024 VA opinion states hiatal hernia was less likely due to the Veteran's service in the Southwest Asia theater of military operations, apparently solely because it was not a presumptive disease. 

There is also a prior VA opinion that the Board found inadequate in a prior remand. 

The Board notes that all the VA opinions fail to address the relevant medical question: was the current stomach disability (hiatal hernia) manifested in service. Based on the evidence of record, the Veteran had stomach symptoms in service - which are documented in service medical records - that may have decreased or lessened close to separation. Stomach symptoms, which the Veteran contends are the same or similar to the in-service symptoms, are documented again in the medical evidence from 2005 and have been ongoing since. Although the in-service symptoms were unexplained at the time and the Veteran believed he had a parasitic illness, the medical evidence states that the symptoms were not parasitic in nature. 

The Veteran contends that the symptoms continued from service in the 1980s until the present. No medical professional ever stated that the Veteran's lay statements were inconsistent or not supported by the other evidence. One VA opinion did note that the Veteran had no heartburn or indigestion symptoms in service. However, the opinion did not state if such symptoms would have necessarily or probably have existed. The Veteran does not currently have symptoms of heartburn or indigestion due to hiatal hernia. 

The Veteran clearly had stomach symptoms, attributed to other causes (GERD, for example), for many years prior to the diagnosis of a hiatal hernia. The most reasonable and probable explanation is that the hiatal hernia symptoms started in service, as the Veteran claimed in his lay statements, and medical professionals only identified the underlying disability relatively recently, in the 2010s. No VA medical opinion clearly states, with adequate rationale, that the in-service symptoms were not manifestations of a hiatal hernia, and they are otherwise unexplained. The lay statements therefore are undisputed. Given the above, the claim for service connection for a hiatal hernia is granted. 

REASONS FOR REMAND

1. Entitlement to a disability rating in excess of 10 percent from August 27, 2014, for right knee degenerative joint disease with instability (Diagnostic Code (DC) 5010-5257) is remanded & 2. Entitlement to a disability rating in excess of 10 percent from August 27, 2014, for left knee degenerative joint disease with instability (DC 5010-5257) is remanded.

The Board denied the above claims in February 2024. In January 
 they are otherwise unexplained. The lay statements therefore are undisputed. Given the above, the claim for service connection for a hiatal hernia is granted. 

REASONS FOR REMAND

1. Entitlement to a disability rating in excess of 10 percent from August 27, 2014, for right knee degenerative joint disease with instability (Diagnostic Code (DC) 5010-5257) is remanded & 2. Entitlement to a disability rating in excess of 10 percent from August 27, 2014, for left knee degenerative joint disease with instability (DC 5010-5257) is remanded.

The Board denied the above claims in February 2024. In January 2025, pursuant to a Joint Motion for Partial Remand (JMPR), the United States Court of Appeals for Veterans Claims (CAVC or the Court) issued an Order setting aside that decision and remanded the matters to the Board. 

The Board notes that since the most recent, February 2024 Board decision, in Ingram v. Collins, the Court held that the Board must discount beneficial medication effects when relevant disability rating criteria do not specifically contemplate medication use. 38 Vet. App. 130 (2025); see Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) ("[T]he Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria.").

VA amended Diagnostic Code 5257 in February 2021. Neither the pre-amendment nor the post-amendment Diagnostic Code 5257 contemplates medication use. 

The last VA examination report of record for the knees, dated January 2023, noted use of ibuprofen. An earlier July 2019 VA examination report notes treatment with injections. 

Therefore, remand is necessary for an additional VA examination with opinion discounting beneficial medication effects. 

2. Entitlement to a disability rating in excess of 10 percent prior to January 3, 2015, for cerebrovascular accident (CVA) with left upper extremity weakness is remanded; Entitlement to a disability rating in excess of 20 percent after January 3, 2015, for CVA with left upper extremity weakness is remanded; and 5. Entitlement to a disability rating in excess of 20 percent for weakness, left lower extremity, is remanded.

A February 2024 Board remand states the following:

In this case, the Veteran's CVA with left upper extremity weakness (Diagnostic Code 8009) is rated pursuant to the criteria for Diagnostic Code 8514, paralysis of the musculospiral nerve (radial nerve). This disability rating is for the severity (mild, moderate, etc.) of paralysis, either complete or incomplete of the radial nerve. During the development of the claim, the Veteran was also rated under Diagnostic Code 8520 for weakness, left lower extremity, associated with CVA. See June 2023 rating decision. This new service-connected disability was included on the Supplemental Statement of the Case dated in August 2023, most likely as a residual of stroke. See Diagnostic Code 8009 (noting, after six months, rate residuals). Code 8520 is for the severity (mild, moderate, etc.) of paralysis, either complete or incomplete of the sciatic nerve.

In September 2022, the Board remanded based on the Veteran's reports of worsening, including have had additional strokes.

A new VA examination for a stroke (Central Nervous System and Neuromuscular Disease Disability Benefit Questionnaire (DBQ)) was obtained in January 2023 and does note worsening. The January 2023 VA examination report does note "moderate" severity for both disabilities. However, while the examination report does report the degree of muscle weakness, the report does not contain the relevant information to evaluate the disability under Code 8514 or 8520. . . . This DBQ used . . . does not contain a box for the sciatic nerve to indicate whether the severity of paralysis was "moderately severe," which would warrant a higher [disability] rating under Diagnostic Code 8520. This information is contained on a different VA examination form (Peripheral Nerves DBQ), which was not used.

Therefore, an additional VA examination to obtain the information needed to evaluate the disabilities under the currently assigned Diagnostic Codes.

The Board instructed the examiner to use the appropriate form, which at the time was the Peripheral Nerves Conditions DBQ.

Unfortunately, in April 2024, a VA examiner again completed a Central Nervous System and Neuromuscular Disease DBQ, not a peripheral nerve VA examination report (currently the Peripheral Nerves Conditions DBQ). As noted
 the sciatic nerve to indicate whether the severity of paralysis was "moderately severe," which would warrant a higher [disability] rating under Diagnostic Code 8520. This information is contained on a different VA examination form (Peripheral Nerves DBQ), which was not used.

Therefore, an additional VA examination to obtain the information needed to evaluate the disabilities under the currently assigned Diagnostic Codes.

The Board instructed the examiner to use the appropriate form, which at the time was the Peripheral Nerves Conditions DBQ.

Unfortunately, in April 2024, a VA examiner again completed a Central Nervous System and Neuromuscular Disease DBQ, not a peripheral nerve VA examination report (currently the Peripheral Nerves Conditions DBQ). As noted in the last Board remand, this DBQ does not contain all the relevant information for rating the disabilities. Therefore, a remand is necessary for the completion of an appropriate examination. 

The matters are REMANDED for the following action:

1. Schedule the Veteran for examinations by an appropriate clinician to determine the severity of the service-connected right knee degenerative joint disease with instability (DC 5010-5257) and the left knee degenerative joint disease with instability (DC 5010-5257).

The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the disability criteria. 

In providing actual and estimated measurements, the examiner is to discount the ameliorative effects of medication and evaluate the baseline severity (i.e., the severity of the disability absent the beneficial effects of medication). 

The Veteran's medications include, but are not necessarily limited to, ibuprofen and injections. 

If it is not possible to provide an opinion without resorting to mere speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or with the examiner (does not have the knowledge or training).

2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the service-connected (1) cerebrovascular accident with left upper extremity weakness and (2) weakness, left lower extremity. 

The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The Veteran is rated based on sciatic and radial nerve involvement and therefore the examiner should use the appropriate form (currently the Peripheral Nerves Conditions Disability Benefits Questionnaire (DBQ)). 

If an examiner only completes a Central Nervous System and Neuromuscular Disease DBQ, the AOJ should inform the examiner that this form does not include the relevant information regarding nerve involvement and severity, and the examiner must provide the relevant information. See 38 C.F.R. § 4.124a, Diagnostic Codes 8514, 8520. In other words, the examiner should either use the Peripheral Nerves Conditions Disability Benefits Questionnaire or, alternatively, separately provide the information required by the regulation regarding nerve involvement and severity. 

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 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.