Gerd Claim

[gousto64]

DECISION

Service connection for hiatal hernia with gastroesophagal reflux disease (claimed as stomach problems and acid reflux secondary to medication for right shoulder separation with impingment and degenerative joint disease) as secondary to the medication used for the service-connection disability of right shoulder disability is denied

REASONS FOR DECISION

We have denied entitlement to service connection for hiatial hernia and gastro esophageal reflux disease as this condition did not occur in service nor is shown to be secondary to the medication used for your service connection right shoulder condition.

Service treatment record are negative for complaints, findings or treatment for Haitian hernia or gerd while in military service.

Private treatment records were reviewed and show complaints of dyspepsia and gerd. A relationship between this condition and your right shoulder condition is not shown.

VA outpatient treatment reports show complaints and treatment for your right shoulder condition, for which you are on diclofenac and methocarbol for pain and muscle symptoms. Complaints of reflux systems are also shown, however, a relationship between these two condition is not of record.

VA examination of Date was reviewed . The Nurse Practitioner indicated that your claim file and medical records were reviewed. For the examination. You

Reported taking ranitidine for stoma problems, acid reflux,and heartburn. You

Reported symptoms of epigastria pain, nausea, vomiting, and indigestion. Physical examination found no signs of significant weight loss or malnutrition. There were no signs of anemia. Upper GI series revealed a fixed Haitian hernia with associated

GERD . In a medical opinion, the examiner stated is as least likely as not that your current complaints of stomach problems and acid reflux are related to the medication prescribed for your service connected shoulder disability. The rational is that the methocarbamol is used as a skeletal muscle relaxant , with side effects of nausea, vomiting, and dyspepsia. Diclofenac is a NSAID that has antipyretic, analgesic, and anti-inflammatory properties. It’s side effects include

Dyspepsia, peptic ulcer disease, and bleeding. Ranitidine is a histamine H2 antagonist that is used to treat heartburn, acid indigestion, and sour stomach, which could prevent

Systems and damage to the gastro esophageal tract caused by stomach acid or infection.

THE NURSE Practitioner stated that a review of the existing data revealed that you developed gastro esophageal problems following taking the prescriptions of diclofenac

And methocarbamol. You were eventually placed on ranitidine to control gastrointestinal effects.

And here’s the bad part known after reading this you will say why did you take another C&P exam answer I didn’t.

On March another VA examination was performed by a staff physician. The

Physician noted that your claims file and medical records were reviewed for the examination. Symptoms reported included daily heartburn, regurgitation, and esophageal

Distress. Physical examination found your overall general health to be fair There were no signs of anemia or significant weight loss/malnutrition. The physician diagnosed you with hiatal hernia with Gerd. The examiner provided an opinion that it was not likely that your current muscle relaxer(mwthocarbamol) and /or pain medication(diclofenac)

Caused the hialat hernia or GERD . He noted that this is based on the fact that the lexi-

Comp online (medication information) shows gastrointestinal adverse effects of methocarbol are nausea,vomiting,metallic taste and dyspepsia. It shows adverse

Gastrointestinal effects of diclofenac are abdominal pain, nausea, and vomiting. The examiner indicated that the statements by the nurse Practitioner are incorrect.

A request was made for the physician to clarify his statement from March > The

Physician responded on June and indicated that he thinks there are two different things. The “stomach problems” such as burning pain, nausea, etc. He agreed that it is at least as likely as not that these symptoms are related to the muscle relawer and pain medications. That opinions based on the face that those things are listed as possible adverse effects of both medications. gastro esophageal junction. Frequently

GERD is found in association with a hiatal hernia. There in nothing in the medical

Literature that supports a claim of pain medications

Causing a hiatal hernia. Therefore, it is the Physicians contention that your hiatal hernia

And sddociated gastro esophageal reflux is not caused by the muscle rexlaxer and/ or pain medications.

The evidence of record shows two competing opinions from a nurse Practitioner and a staff physician.

Probative weight must be assigned for each opinion. The Nurse Practitioner gave a 50/50

Probability that your current complaints of stomach problems and acid reflux are related to the medications used for your right shoulder, based on published side effects listed for those medications . However, the staff physician indicated that you have a hiatal hernia with associated gerd. He indicated that this is a structural problem/ abnormality and there is nothing in the medical literature that shows muscle relaxants or pain medication causing a hiatal hernia. He state that your hiatal hernia and associated Gerd is not caused by medications for the right shoulder. The physician’s opinion is given greater weight based on the educational background of the examiner and the rational provided regarding the etiology of your hiatal hernia and associated reflux.

The available evidence does not show that a hiatal hernia with GERD was treated for or

Diagnosed in service. Additionally, no evidence was submitted to show that hiatal hernia

With GERD is the result of military service or the result of medication used for your

Service connected right shoulder condition. The benefit of the doubt rule does not apply because the preponderance of evidence is unfavorable. Therefore, entitlement to service connection is denied.

Service connection may be granted for a disease or injury which result from a service connected disability or was aggravated thereby. The evidence does not show that hiatal

Hernia with gastro esophageal reflux disease (claimed as stomach problems and acid reflux secondary to medication for right shoulder separation with impingement ) is related to the medications used for the service-connected condition of right shoulder injury nor is there any evidence of this disability during military service.

I NEED HELP WHAT SHOULD I DO NEXT?

[pacmanx1]

Have you ever been treated by a internal medicine doctor (gastroenterologist), you need an IMO to review your records and write a statement on your behalf. I am confused because VA stated:

A request was made for the physician to clarify his statement from March > The

Physician responded on June and indicated that he thinks there are two different things. The "stomach problems" such as burning pain, nausea, etc. He agreed that it is at least as likely as not that these symptoms are related to the muscle relawer and pain medications. That opinions based on the face that those things are listed as possible adverse effects of both medications. gastro esophageal junction. Frequently

GERD is found in association with a hiatal hernia.

What type of physician was he? Was he an internal medicine specialist?

[stillhere]

I agree with Pete you need a IOM that addresses the questions raised in the denial.

I would suggest you take the docs you posted and have the doc read them and if he/she will write a rebuttal and back it up with rationale. That is the only way I feel a appeal will work.

In dealing with the VA you have to fight the written word with the written word. If your doc will not do it then you will have to find either some medical report that supports your contentions or some other health evidence that will.

I would also point out that you want a MD to check you at your next C&P and NOT a NP.

[gousto64]

I do not recall seeing anyone other than a NP . The VA gave only one official C&P exam in Feb and they say that in March i was given a second unofficial C&P exam because I was'nt aware of a second C&P Exam .

[MikeR]

I would have to concur with these gentlemen, you need someone in your corner. Just because these clowns at the VA say it so, does not make it so. Get the IMO from the best doctor your can afford and have him write an opinion. Many Doctors write these letters very often and if you tell them it's for the VA that they are denying reality they will wirte them with a special relish. One Board Certified doc of mine really enjoyed picking the VA doc apart and generally with a good IMO the VA docs will back down and not argue a wrong point. You just have to challenge the madness.

[LarryJ]

First. have you gotten copies of your C&P in February and March. Does the paperwork "match-up" (do the names, claim number, etc. match-up), because I have seen several C&P's and medical Progress Notes, SMR's and SMT's, that are for TWO (and one I saw was for THREE) different veterans.

Check this out before you do anything.

Then, request a DRO review/hearing.

There is a plethora of medical evidence on the internet that attests to the fact that GERD is MOST CERTAINLY associated with medications such as NSAIDS, etc. (I KNOW, personally, about that). Print all this evidence off, AND, as has been suggested, get an IMO, preferably from a Internal Medicine doctor. Get this in to the VARO ASAP, by doing so you may eliminate the hearing, when the DRO gets a chance to look at your evidence. And, don't let them BS you into thinking that you had TWO C&P's...........because they didn't like the FIRST C&P......they just got a MORE FAVORABLE to the VA, opinion from their SECOND examiner (who, most probably, read the ONLY C&P that you had, and picked it apart as he was instructed to do). Doctor shopping for a better denial is AGAINST VA Policy...............and, I'd damn sure make sure that that fact is placed before the DRO and let the DRO know that it will be the first thing brought to light IF, IF, your claim goes to the BVA. Fill out a form #21-4138 making this statement your number ONE on the page, then list the evidence that you have uncovered on the internet (itemized list to match your attachments) and then list the opinion of your IMO along with his/her speciality training, etc.

And, don't let the year run out on filing an NOD, if you haven't had your DRO review/hearing.

[mags1023]

These folks are exactly right! I was awarded 10% for the same conditions you have (hiatal hernia/gastritis) secondary to medication prescribed to treat chronic pain from service connected cervical spine condition. All NSAIDs. The VA C&P examiner (a PA) of course found against my claim and said it was not caused by NSAIDs, but I have private insurance (TRICARE) and had the doc that performed my endioscopy sign a letter that he believed NSAIDs were " at least as likely as not" a causual factor and that he instructed me to have my primary physician discontinue the use of Mobic or Motrin and try tramadol. Bottom line is get an IMO like this from a DR. Hope this helps. s/Mags