Citation Nr: 1303806 Decision Date: 02/04/13 Archive Date: 02/08/13 DOCKET NO. 08-29 353 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for headaches, including as residuals of a broken nose. 2. Entitlement to service connection for a sinus disorder, including as residuals of a broken nose. 3. Entitlement to service connection for a skin disorder, to include chronic hives. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran served on active duty from June 1965 to May 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision by the North Little Rock, Arkansas, Regional Office (RO) of the Department of Veterans Affairs (VA). In August 2009, the Veteran testified at a hearing before the undersigned Veterans Law Judge, seated at the RO (i.e. Travel Board hearing). A transcript has been procured for the record. In March 2010, the Board remanded the Veteran's claims on appeal to the Appeals Management Center (AMC) for additional development. The record indicates that the AMC complied with the Board's requests regarding the issue of service connection for headaches, including the procurement of additional VA treatment records and the provision of a VA medical examination to determine the nature and etiology of the claimed headache disorder. As the AMC complied with the March 2010 Remand directives regarding the issue of service connection for headaches, the Board will proceed to render decisions regarding this claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). Regarding the Veteran's claim for service connection for a skin disorder, as will be explained in the Remand section, the record indicates that the AMC/RO provided a VA medical examination to determine the nature and etiology of the claimed skin disorder in June 2010. However, the Board finds that the June 2010 VA medical examination report is inadequate. Therefore, the claim for a skin disorder must be remanded for the provision of an additional VA medical examination. See id. Regarding the Veteran's claim for service connection for a sinus disorder, the record indicates that the AMC complied with the Board's March 2010 remand requests regarding the procurement of VA treatment records and the provision of a June 2010 VA medical examination to determine the nature and etiology of the claimed sinus disorder. However, the AMC did not subsequently associate a copy of the June 2010 VA medical examination report with the claims file. As the Board needs to be able to review a copy of that examination to weigh the evidence of record, the Board must remand the issue of a service connection for a sinus disorder for the AMC to procure a copy of the June 2010 VA medical examination report regarding the nature and etiology of the Veteran's claimed sinus disorder and associate it with the claims file. In June 2011, the Veteran filed additional claims for service connection for a sleep disorder, to include as secondary to service-connected disabilities, and diabetes. The record contains no indication that the RO has performed any development regarding these issues. Therefore, the issues of service connection for a sleep disorder, to include as secondary to service-connected disabilities, and diabetes are referred to the RO for further development. The issues of service connection for skin and sinus disorders are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran did not experience chronic headache disorder symptomatology during service. 2. The Veteran did not experience headache disorder symptomatology more nearly approximating that of characteristic prostrating attacks averaging one in two months within one year after the date of his discharge from service. 3. The Veteran did not experience continuous headache symptomatology after discharge from service. 4. The Veteran's current headache disorder, diagnosed as vascular headaches, is not related to service or any incident of service, to include a claimed broken nose. CONCLUSION OF LAW The criteria for service connection for a headache disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide veterans with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify a veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. In order to meet the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must (1) inform the veteran about the information and evidence necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; and (3) inform the veteran about the information and evidence the veteran is expected to provide. VCAA notice should be provided to a veteran before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (1) the veteran's status; (2) the existence of a disability; (3) a connection between the veteran's service and the disability; (4) the degree of disability; and (5) the effective date of the disability. The Court held that, upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim, and to provide the veteran with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. A June 2007 VCAA notice letter satisfied the provisions of 38 U.S.C.A. § 5103(a). In this letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information regarding the type of evidence necessary to establish a disability rating or effective date for the disability on appeal required by Dingess. The Board finds that all necessary assistance has been provided to the Veteran. VA has acquired the Veteran's service, VA, and private treatment records to assist the Veteran with the claim and the Board is not aware of any additional relevant evidence which is available but has not been obtained. In June 2010, VA provided the Veteran with a VA medical examination to determine the nature and etiology of the claimed headache disorder. As the June 2010 VA medical examination report was written after a review of the claims file, an interview with the Veteran, an examination of the Veteran, and contains findings regarding the nature and etiology of the claimed headache disorder, supported by clinical data, the June 2010 VA medical examination report is adequate for VA purposes. Under these circumstances, there is no duty to provide an additional medical examination or opinion. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Service Connection Criteria Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304 (2012). That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). 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). To establish service connection, generally, there must be (1) a medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999), citing Caluza v. Brown, 7 Vet. App. 498 (1995). In addition, the law provides that, where a Veteran served 90 days or more of active service, and certain chronic diseases, such as organic diseases of the nervous system (e.g,, migraine), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the veteran. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence that does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Board has reviewed all of the lay and medical evidence in the Veteran's claims folder. A veteran normally is competent to report the symptoms and impairments associated with a psychiatric disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (holding that lay statements may serve to support a claim by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability that are susceptible of lay observation). The Board has not discounted lay evidence regarding the Veteran's psychiatric symptomatology because it is lay evidence or because it was reported by the Veteran. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (holding that a history given by a veteran that has not been found by the Board to be inaccurate is not a basis for discounting an opinion based on that history). That being said, the Board has an obligation to determine the credibility of all evidence, lay and medical. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the duty to assess the credibility and weight to be given to the evidence). The Board has considered all evidence of record as it bears on the question of service connection. See 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. Service Connection for Headaches The Veteran essentially contends that he developed headaches during an incident in service. Specifically, the Veteran contends that he developed headaches due to a broken nose that he incurred during service. After a review of all evidence, lay and medical, the Board finds that the preponderance of the evidence weighs against the Veteran's claim for service connection for headaches. The Board finds that the Veteran did not experience chronic headache disorder symptomatology during service. In a June 1965 service induction medical examination report, a service examiner diagnosed the Veteran as having no abnormalities at the time of examination, with the exception of pes planus. In a contemporaneous June 1965 report of his own medical history at induction, the Veteran denied having ever experienced frequent or severe headaches, but indicated that he had experienced eye trouble. Subsequent service treatment records contain no notation indicating diagnosis or treatment for headaches during service. In a January 1967 service separation medical examination report, a service examiner diagnosed the Veteran as having no abnormalities at the time of examination. In a contemporaneous January 1967 report of his own medical history, the Veteran denied ever experiencing frequent or severe headache, but indicated that he had experienced eye trouble. In a physician's summary included on the January 1967 report of the Veteran's medical history, a service examiner wrote that the Veteran had experienced headaches two years ago that were thought to be due eyestrain. In a May 1967 statement of medical conditions, provided at discharge from service, the Veteran specifically denied experiencing any change in his medical condition since the January 1967 service separation medical examination. As noted above, on the January 1967 report of the Veteran's medical history, a service examiner wrote that the Veteran had experienced headaches two years ago that were thought to be due eyestrain. The Board notes that the Veteran did not enter service until June 1965 so the service examiner's notation, indicating that the Veteran experienced headaches two years prior, is ambiguous as to whether such headaches occurred during service. In other notations on the January 1967 report of the Veteran's medical history, the service examiner listed disorders that occurred years before the Veteran's service, specifically childhood mumps and whooping cough, and a dislocated left shoulder that the Veteran incurred three years prior to his entry into active service. Therefore, the January 1967 report of the Veteran's medical history does not, in itself, indicate that the Veteran experienced headaches during service. Moreover, as the service examiner did not indicate any recurrence of headaches within the previous two years, the service examiner's notation in the January 1967 report of the Veteran's medical history weighs against a finding of chronic in-service headache symptomatology. As noted above, the other service treatment records contain no notation indicating diagnosis or treatment for headaches. Moreover, in the January 1967 report of his medical history, the Veteran himself denied ever experiencing frequent or severe headache. Therefore, the Board finds that the contemporaneous medical evidence, specifically the service treatment records, weigh against a finding of chronic headache disorder symptomatology during service. In his lay statements, the Veteran did not report experiencing chronic headache disorder symptomatology during service. In the first record in the claims file indicating contemporaneous treatment for headache symptomatology, specifically an April 2000 private treatment record, the Veteran reported experiencing sinus headaches off and on over the previous month. At the August 2009 Travel Board hearing, the Veteran testified that he began experiencing headache symptomatology in 1970, but later suggested that he experienced onset of headaches at an undefined date prior to 1970. In a June 2010 VA medical examination report, the Veteran stated that he started experiencing very mild headaches about a year after his discharge from service, in approximately 1968. The Veteran indicated that the headaches became severe about three years after discharge, in about 1970. Therefore, in his lay statements, the Veteran reported experiencing post-service onset of symptomatology related to the claimed headache disorder. By contrast, in a June 2011 sworn lay statement, the Veteran's ex-spouse stated that that she was married to the Veteran from August 1965 to August 1992, and had observed his medical conditions from service until the present day. In this letter, the Veteran's ex-spouse wrote that she had seen the Veteran experiencing headaches during and after service of such severity that they depressed him to the point of being unable to function. In evaluating evidence, to include lay evidence, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza, 7 Vet. App. at 511-12 (1995); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). In this instance, the service treatment records contain no notation indicating treatment or diagnosis for in-service headaches, other than the ambiguous notation about headaches related to an eye disorder included in the January 1967 report of the Veteran's medical history. In the medical history report, the Veteran himself remarked that he had not experienced recurrent or severe headaches. In post-service lay statements submitted in support of his claim for service connection, the Veteran has consistently maintained that his claimed headaches symptomatology began at some point after his discharge from service. Therefore, the Board finds that the Veteran's ex-spouse's June 2011 sworn lay statement, indicating that the Veteran experienced debilitating headaches during service, is not credible as it is inconsistent with the both the lay and medical evidence of record. See id. Therefore, the Board finds that the preponderance of the evidence, both lay and medical, weighs against a finding of chronic headache disorder symptomatology during service. The Board also finds that the Veteran's claimed headache disorder did not become manifest to a degree of 10 percent or more within one year after the date of separation from such service and, therefore, cannot be presumed to be service-connected. In order to qualify for a 10 percent rating under the applicable diagnostic code, specifically that used for rating migraines, a Veteran's headaches must be manifested by symptomatology more nearly approximating that of characteristic prostrating attacks averaging one in two months over the last several months. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). The claims file contains no post-service treatment records indicating treatment for a headache disorder, to include migraines, dated prior to April 2000. In the June 2010 VA medical examination report, the Veteran reported experiencing mild headaches about a year after service and indicated that the headaches did not become severe until three years after service. The Veteran's statements, provided to the June 2010 VA examiner, do not indicate migraine headaches manifested by symptomatology more nearly approximating that of characteristic prostrating attacks averaging one in two months required for a 10 percent rating under Diagnostic Code 8100. See id. As noted above, in the June 2011 sworn statement, the Veteran's ex-spouse wrote that she had seen the Veteran experiencing headaches of such severity that they depressed him to the point of being unable to function after service. In this instance, the Board notes that the Veteran's ex-spouse's statement did not specifically state that she saw the Veteran experiencing such severe headache disorder symptomatology within the one-year period after the Veteran's discharge from service. Moreover, had the Veteran's ex-spouse written that she witnessed the Veteran experiencing severe headache symptomatology within a year of his discharge from service, the Board would find such statement to lack credibility as it is inconsistent with the Veteran's report, indicating that he experienced only mild headaches soon after service. See Caluza, at 511-12. In addition, the Veteran's ex-spouse did not indicate that the Veteran specifically experienced the characteristic prostrating attacks suggestive of migraines. Therefore, the Board finds that the evidence weighs against a finding of headache disorder symptomatology more nearly approximating that of characteristic prostrating attacks averaging one in two months over the last several months within a year of the Veteran's discharge from service. Therefore, the Veteran's headache disorder may not be presumed to be related to service. The Board finds that the Veteran did not experience either continuous headache disorder symptomatology since discharge from service. As noted above, the first post-service treatment record indicating diagnosis and treatment for a headache disorder included in the claims file is dated April 2000, over 34 years after the Veteran's discharge from service. In this report, specifically a history and physical report for the offices of an otolaryngologist, the Veteran reported experiencing sinus headaches off and on over the previous month. The Veteran stated that the headaches were primarily frontal, and that he would be bothered by lights and noise during an attack. The diagnosis was questionable headaches. In a September 2002 private treatment record, the Veteran indicated that he experienced sinus headaches occasionally, but stated that he had not experienced any such headaches over the previous four to five years. In an April 2006 VA treatment record, the Veteran reported that he had been experiencing what he considered to be sinus disorder symptoms, to include headaches, over the previous two weeks. After examination, the VA examiner diagnosed sinusitis versus migraine. In an October 2007 VA treatment record, the Veteran reported experiencing severe but rare headaches with photophobia and incapacitation. The Veteran stated that he experienced the last such headache approximately five to six years prior to the examination. At the August 2009 Travel Board hearing, the Veteran stated that he began to have headaches in 1970. He indicated that these headaches would start when the right side of nostril would become congested. The Veteran indicated that, at the time, a private examiner told the Veteran that he was having acute sinus headaches, cluster headaches, or migraines. At the same hearing, under questioning from his representative, the Veteran indicated that he took over-the-counter medication to treat his headaches prior to seeing a doctor in 1970. As such, the Veteran left the date of onset for his headaches ambiguous. In a June 2010 VA medical examination report, the Veteran stated that he started experiencing very mild headaches about a year after his discharge from service. The Veteran indicated that the headaches became severe about three years after discharge. The Veteran reported experiencing headaches about once every three to four months, lasting about 30 to 45 minutes per episode. In a June 2011 lay statement, the Veteran's ex-spouse indicated that she saw the Veteran experiencing headaches during and after service of such severity that they depressed him to the point of being unable to function. From this record of evidence, the Board finds that the preponderance of the evidence weighs against a finding of continuous headache symptomatology disorder since the Veteran's discharge from service. The medical evidence of record does not indicate that the Veteran experienced continuous headache symptomatology or even regularly recurring symptomatology of the described headache symptoms since his discharge from service. The treatment records on file indicate sporadic headache symptomatology with several years passing between any recurrence of symptoms. In the April 2000 private treatment record, the first such record indicating post-service treatment for a headache disorder included in the claims file, the Veteran reported experiencing sinus headaches off and on over the previous month. However, in the subsequent September 2002 private treatment record, the Veteran indicated that he had not experienced any headaches over the previous four to five years. In an April 2006 VA treatment record, the Veteran reported sinus disorder symptoms, to include headaches, over the previous two weeks. Yet, in the October 2007 VA treatment record, the Veteran reported experiencing severe headaches, but also indicated that such headaches were rare and that he had not experienced such a headache in five to six years. In reviewing the lay evidence, the Board finds that the Veteran did not report experiencing continuous headache disorder symptomatology since service. As noted above, in the June 2010 VA medical examination report, the Veteran reported experiencing mild headache symptomatology about a year after service that became severe three years after service. The Veteran did not report experiencing continuous headache disorder symptomatology after that treatment. In the June 2011 sworn statement, the Veteran's ex-spouse indicated that the Veteran experienced headaches after service, but did not indicate that such symptoms were continuous. Therefore, the Board finds that the evidence weighs against a finding of continuous headache disorder symptomatology after the Veteran's discharge from service. Finally, the Board finds that the Veteran's headaches are not related to service or any incident in service, to include a broken nose. At the August 2009 Travel Board hearing, the Veteran testified that he broke his nose while serving in Germany in 1966 while he and his fellow service members were away from their base for several days delivering mail. The Veteran indicated that, on the second day away from the base, he and his fellow service members decided to eat lunch underneath a five-ton carrier that guided a satellite. The Veteran recalled that he stood up too early and hit his nostrils on the carrier's tailgate while attempting to get out from under the carrier after he had finished eating. The Veteran reported asking his squad leader if he should go to the local health clinic, but the sergeant said that his nostrils looked okay and told him to wait until he returned to his normal station for treatment. The Veteran indicated that he went on sick call when he returned to his normal duty station, but, as the swelling had subsided, his nostrils appeared normal. The service examiners at sick call, after examining the Veteran, told him to return to duty. The Veteran testified that he sought medical treatment for headaches after service in 1970. At that time, a private examiner told him that he had broken his nose during service and that this was causing his headaches. During the Travel Board hearing, the Veteran could not say for certain if an examiner had ever performed a sinus X-ray or a sinus series to confirm the claimed nasal fracture. Reviewing the medical evidence, in an April 2000 private CT scan of the paranasal sinuses report, a private examiner reported that the Veteran had a minimal nasal septal deviation. The private examiner diagnosed the Veteran as having chronic sinusitis. In a June 2010 VA medical examination report, the Veteran stated that he started experiencing very mild headaches about a year after his discharge from service. The Veteran indicated that the headaches became severe about three years after discharge. The Veteran reported that the headaches were manifested by sharp and pulsating pain located at the right side of his head. The Veteran stated that the pain was accompanied by light and noise sensitivity, but not nausea and vomiting. The Veteran indicated that his family history was negative for headaches. The Veteran reported experiencing headaches about once every three to four months, lasting about 30 to 45 minutes per episode. The Veteran stated that he took Zomig to treat the headaches and that the medication appeared to help. The Veteran indicated that, upon the beginning of a headache episode, he would be unable to work and would have to lie down in a dark, quiet room. The Veteran reported that he would know that a headache was about to occur because his sinuses would become clogged about 15 to 30 minutes before headache onset. The Veteran stated that he did not have any trigger signs associated with the headaches. Upon examination, the VA examiner noted that the Veteran's head was normocephalic without any signs of trauma. The Veteran's pupils were both equal and reacted to light. After further examination and a review of the entire claims file, the VA examiner stated that he thought that the Veteran had nonspecific vascular headaches that were not service-connected. The VA examiner indicated that the Veteran's warning signs regarding his headaches seemed to indicate sinus disease, but the VA examiner believed that the Veteran only had mild vascular headaches. The VA examiner indicated that the service treatment records contained no documentation indicating that the Veteran experienced the types of headaches he currently experiences during service. The examiner noted that the Veteran specifically indicated that the headaches did not begin until one year after service and then became severe three years after service discharge. The Board notes that, in the January 1967 report of his medical history for separation, the Veteran reported experiencing headaches two years prior thought to be due to eyestrain. This suggests that the Veteran might have experienced some form of headache during service, although the notation could also indicate that the Veteran experienced headaches prior to his June 1965 service entrance. Although the June 2010 VA examiner did not specifically note this notation in the June 2010 VA medical examination report, the VA examiner opined that the Veteran did not experience the type of headache he currently experienced, specifically vascular headaches unrelated to eyestrain, during service. The Board notes that this finding is in keeping with the evidence, to include the Veteran's consistent statements, indicating onset of his current type of headaches, described by him as migraines or cluster headaches, after his discharge from service. As the VA examiner wrote the June 2010 VA medical examination report after an interview with the Veteran, a medical examination, and a review of the claims file, and offered an opinion regarding the etiology of the Veteran's current headache disorder, based on all evidence of record, the Board finds the June 2010 VA medical examination report has great probative value in this matter. See Prejean v. West, 13 Vet. App. 444, 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail, the persuasiveness of their opinions, and the physicians' access to a veteran's medical records); 38 U.S.C.A. § 5103A(d);38 C.F.R. § 3.159(c)(4). The Board notes that the Veteran has contended that he developed headaches due to a 1966 in-service nasal fracture and was told by a doctor that the nasal fracture caused his headaches. However, the Board notes that the service treatment records, to include the January 1967 service separation examination report, contain no notation indicating treatment or diagnosis for a broken nose during service. Moreover, in his own report of his medical history in January 1967, the Veteran did not indicate experiencing a broken nose. The Veteran has not provided any medical opinions indicating a nexus between the claimed broken nose and his current headache disorder. Moreover, in the April 2000 private CT scan of the paranasal sinuses report, a private examiner reported that the Veteran had only a minimal nasal septal deviation and not a fracture of the nose. Considering this evidence, the Board finds that the Veteran's reports of experiencing a broken nose during service, and the Veteran's statements indicating that the broken nose caused his current headaches, lack credibility as they are inconsistent with the other evidence of record to include the Veteran's own statements. See Caluza, at 511-12. For these reasons, the Board finds that the preponderance of evidence weighs against the claim for service connection for headaches and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for headaches, including as residuals of a broken nose, is denied. REMAND The Board finds that additional development is required regarding the respective issues of service connection for a skin disorder and a sinus disorder prior to Board adjudication. 38 C.F.R. § 19.9 (2012). Regarding the issue of service connection for a skin disorder, the Veteran essentially claims that he developed a skin disorder, to include recurrent hives, during active service. When specifically questioned about the potential cause of the claimed skin disorder, the Veteran could not recall coming into contact with any foreign substance known to cause a skin reaction during service. At the August 2009 Travel Board hearing, the Veteran stated that he was diagnosed as having hives in 1967 while stationed in Germany. The Veteran reported being hospitalized for three to four days for this disorder. The Veteran indicated that, initially, his whole body was covered with hives and, on the second day, the disorder spread to his genital areas. The Veteran reported experiencing stinging itching and open sores on the head of his penis. The Veteran indicated that he was provided with antibiotics and that the condition cleared up after a week or ten days with cream use. Reviewing the service treatment records, in a September 1965 service treatment record, a service examiner diagnosed the Veteran as having a "rash." The service examiner prescribed phisohex soap for treatment of the disorder. In a January 1967 service separation medical examination report, a service examiner diagnosed the Veteran as having no skin abnormalities at the time of examination. In a contemporaneous January 1967 report of his own medical history, the Veteran denied ever experiencing asthma, hay fever, or hives. In a May 1967 statement of medical conditions, provided at discharge from service, the Veteran specifically denied experiencing any change in his medical condition since the January 1967 service separation medical examination. Reviewing the post-service evidence, in a September 2002 private treatment record, the Veteran reported experiencing hives over the previous 20 years. The private examiner diagnosed recurrent idiopathic urticaria. Subsequent treatment records dated since October 2006 also indicate treatment for tinea versicolor. In an August 2007 claim for benefits, the Veteran claimed service connection for genital herpes and bacterial pyoderma in addition to the skin disorders currently on appeal. The Veteran indicated that he was hospitalized during service in Germany for diagnosed bacterial pyoderma, which he described as small, dry, crusting lesions on the penis and a rash on the crotch. In the February 2008 rating from which this appeal arises, the RO denied the Veteran's claims for service connection for both genital herpes and bacterial pyoderma. However, the Veteran did not appeal these issues to the Board and the RO's February 2008 respective denials of service connection for genital herpes and bacterial pyoderma became final. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012). In a June 2010 VA medical examination report, provided to determine the nature and etiology of the Veteran's claimed skin disorder, the Veteran reported experiencing hives all over his body with severely pruritic areas during service in Germany in 1967. The Veteran indicated that he was hospitalized for three days for this disorder during service. The Veteran indicated that he experienced an episode of raised red, pruritic hives from his head to his feet about every three months, lasting two to three days per episode. The Veteran reported that he did not experience any trigger event prior to these episodes. The Veteran stated that the hives were not ulcerating, crusting, exfoliating, exudative, or disfiguring, but were itchy. The Veteran indicated that he used a topical cream to treat this disorder. The Veteran reported that he did not experience any papules or discharge. The Veteran stated that the disease was intermittent and had not progressed. In reviewing the claims file, the VA examiner noted that the Veteran's 1967 service discharge medical examination report was normal and that the Veteran's 1967 report of his medical history at discharge indicated that the Veteran had been treated solely for eyestrain, strep throat, and a dislocated shoulder, but not a skin condition. The VA examiner noted that a private allergist diagnosed the Veteran as having recurrent idiopathic urticaria in 2002. The VA examiner also noted that the Veteran had limited reactivity to mold and indoor allergens. The VA examiner also noted VA records indicating allergic reactions to chocolate and cheese, causing hives. The VA examiner noted that the Veteran had been diagnosed as having questionable tinea versicolor on the back in October 2006. The VA examiner reported examining the Veteran's skin from the scalp to the feet. The VA examiner noted finding no raised areas, hives, redness, whelps, or any pruritic areas upon examination. The VA examiner reported finding an area that was slightly hypopigmented on the Veteran's mid-back. The VA examiner indicated that there was no scaling in this area and that the area was not pruritic. The VA examiner noted that the area was consistent with tinea versicolor. The VA examiner diagnosed tinea versicolor on the mid-back, covering approximately five percent of the Veteran's entire body area and zero percent of the exposed body area; and recurrent idiopathic urticaria by history, currently covering zero percent of the Veteran's body area. After a review of the claims file, the VA examiner stated that the Veteran's tinea versicolor was not related to service. The VA examiner noted that the tinea disorder was of a different nature than that described by the Veteran in his statements supporting his claim. Moreover, the tinea disorder was first diagnosed in 2006, nearly four decades after the Veteran's discharge from service. Regarding the recurrent idiopathic urticaria, the VA examiner found that the disorder was not caused by or aggravated by the Veteran's service. The VA examiner reported being unable to find any objective evidence in the medical records, to include his own physical examination, indicating that the skin disorder began in service or was aggravated by the Veteran's service. The VA examiner noted that the service treatment records contained no mention of treatment for this rash during service, the service discharge medical examination report indicated that the Veteran's skin was normal, and the Veteran's report of his medical history at discharge contained no notation indicating that he had experienced hives during service. While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). As noted above, the June 2010 VA examiner found that the Veteran's current skin disorder, specifically recurrent idiopathic urticaria, was not at least as likely as not related to service or any incident in service, because the Veteran's service treatment records contained no mention of "this rash" during service. However, the Board notes that the Veteran's service treatment records contain a single notation indicating treatment for a rash in September 1965. The VA examiner did not provide any explanation as to why the "rash" the Veteran currently experienced was different than the rash the Veteran experienced during service. The Court has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). As the record of evidence indicates that the Veteran experienced a "rash" during service and the June 2010 VA examiner did not adequately explain why the Veteran's current rash was different than that incurred during service, the June 2010 VA medical examination report is inadequate and another VA examination should be provided. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA undertakes the effort to provide an examination, it must provide an adequate one). In addition, in June 2010, VA provided the Veteran with a VA medical examination to determine the nature and etiology of the claimed sinus disorder. The AMC did not subsequently incorporate a copy of this examination report with the claims file. Therefore, the case must be remanded to procure a copy of the June 2010 VA medical examination report regarding the Veteran's claimed sinus disorder. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should contact the Veteran and request that he identify specific names, addresses, and approximate dates of treatment for all health care providers who provided treatment for the claimed skin disorder. At a minimum, the AMC/RO should procure any VA treatment records dated after May 6, 2011 the date of the last VA treatment record included in the claims file. 2. After the completion of the above, the AMC/RO should schedule the Veteran for a VA medical examination to assist in ascertaining the nature and etiology of the skin disorder. The claims folder (including all relevant Virtual VA documentation) should be provided to the VA examiner and should be reviewed by the VA examiner in connection with the examination. In reviewing the claims file, the VA examiner should note any treatment records and lay evidence indicating treatment for a low back disorder, to include: a. The September 1965 service treatment record diagnosing the Veteran as having a "rash" and prescribing phisohex soap for treatment of the disorder; b. The January 1967 service separation medical examination report; c. The January 1967 report of the Veteran's medical history; d. The September 2002 private treatment record diagnosing idiopathic urticaria; e. The October 2006 VA treatment record diagnosing tinea versicolor; f. The January 2008 VA treatment record, diagnosing a skin disorder related to allergies; g. The Veteran's August 2007 claim for benefits, indicating in-service hospitalization for genital herpes and bacterial pyoderma, affecting the penis and genital area; h. The Veteran's August 2009 testimony, indicating in-service hospitalization for idiopathic urticaria, affecting the penis and genital area; i. The June 2010 VA medical examination report; j. The Veteran's ex-spouse's June 2011 sworn statement. After an interview of the Veteran, a physical examination, and all tests and studies required, the VA examiner should offer the following opinion: Is it at least as likely as not (50 percent or greater probability) that any current skin disorder is related to the Veteran's service or any incident of service? A rationale should be provided for any opinion or conclusion expressed. 3. The AMC/RO should procure a copy of the June 2010 VA medical examination report, provided to determine the nature and etiology of the Veteran's claimed sinus disorder, and associate it with the claims file. 4. After completion of the foregoing and all other necessary development, the AMC/RO should re-adjudicate the issues of service connection for a skin disorder and a sinus disorder. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs