Citation Nr: 1325855 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 11-24 853 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for migraine headaches. ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from September 1989 to May 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In that rating decision, the RO granted service connection for migraine headaches and assigned a 10 percent evaluation effective from January 22, 2010. The Veteran appealed the assigned initial evaluation. In addition to the paper claims file, there is a Virtual VA paperless file associated with the Veteran's case. A review of the documents in the paperless claims file reveals documents that are either duplicative of the evidence in the paper claims file or irrelevant to the issue on appeal. The Board also notes that, in an August 2010 rating decision, the RO granted service connection for degenerative arthritis of the left knee and assigned a 10 percent evaluation effective from January 22, 2010. The Veteran submitted a notice of disagreement with the assigned initial evaluation in September 2011, and in July 2012, the RO issued a statement of the case. Nevertheless, the Veteran has not submitted a substantive appeal with respect to this issue; therefore, the issue is not currently on appeal. See 38 U.S.C.A. § 7105 (2012). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND In a September 2011 VA Form 9, the Veteran indicated that his service-connected migraine headaches had increased in severity since his last VA examination in May 2010. Additionally, he stated that his headaches left him "unable to carry out [his] daily work duties." Specifically, he reported that he was unable to deliver a critical presentation, missed a leadership meeting during a recent business trip, had to work from home and/or leave work early on occasion, and was absent from work five times over the past three months due to his migraine headaches. VA's General Counsel has indicated that when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, the Board finds that an additional VA examination is necessary for the purpose of ascertaining the current severity and manifestations of the Veteran's service-connected bilateral hearing loss. A review of the record also shows that there may be additional private treatment records that have not been associated with the claims file. Specifically, a March 2010 private treatment note references treatment at a private neurology clinic earlier in March 2010. However, it does not appear that any action has been taken to obtain these records. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his service-connected migraine headaches. After acquiring this information and obtaining any necessary authorization, the RO/AMC should obtain and associate these records with the claims file. The RO should specifically request that the Veteran provide a signed authorization to enable it to obtain all outstanding pertinent medical treatment records from the private neurology clinic referenced in the March 2010 private treatment note in the claims file. A specific request should also be made for any outstanding VA medical records. If any records are not available, the Veteran should be notified. 2. The RO/AMC should request that the Veteran provide the name and address of his employer to obtain any relevant employment records documenting his use of sick leave and/or an inability to perform work duties due to his migraine headaches. After acquiring this information and obtaining any necessary authorization, the RO/AMC should obtain and associate these records with the claims file. If any records are not available, the Veteran should be notified. 3. After completing the preceding development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected migraine headaches. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected disability. The examiner should report all signs and symptoms necessary for rating the Veteran's migraine headache disability under the rating criteria. In particular, the examiner should comment as to whether the Veteran's migraine headaches are productive of: (a) characteristic prostrating attacks averaging one in 2 months over the last several months; (b) characteristic prostrating attacks occurring on an average once per month over the last several months; or, (c) very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability This VA examination should also include a statement as the effect of the Veteran's migraine headaches on his occupational functioning and daily activities. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After completing the above actions, the RO/AMC should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 5. When the development requested has been completed, the case should be reviewed by the RO/AMC on the basis of all additional evidence. If the benefits sought are not granted, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim 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). _________________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).