Citation Nr: 18143654 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 16-31 854 DATE: October 19, 2018 REMANDED Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for a bilateral foot disorder, to include peripheral neuropathy, is remanded. REASONS FOR REMAND The Veteran served honorably in the Army from October 1981 until September 1982. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Although the Veteran submitted a Rapid Appeals Modernization Program (RAMP) opt-in election form in August 2018, the appeal had already been activated at the Board and was thus no longer eligible for the RAMP program. In September 2018, the Veteran was notified that she did not have an appeal eligible for RAMP. This appeal has been advanced on the docket. 38 U.S.C. § 7107 (2012); 38 C.F.R. § 20.900(c) (2018). 1. Entitlement to service connection for migraine headaches. Remand is required for a VA examination. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with a migraine headaches examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the Veteran’s private treatment records and VA treatment records show regular and current treatment for migraines. A June 1982 service treatment record (STR) showed a complaint of a headache. The Veteran alleges that his migraine headaches began during service and have existed since that time. Because there is evidence of currently diagnosed disabilities, an in-service event, and an indication that the current disabilities may be associated with the in-service event, remand for a VA examination is required. 2. Entitlement to service connection for a bilateral foot disorder, to include neuropathy. Remand is required to secure an adequate VA examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran alleges her foot pain began during service and has existed since that time. The Veteran received a VA examination in July 2012. The examiner noted the date of onset of symptoms as October 1985. Additionally, the examiner noted the Veteran stated she experienced foot pain in service while running in boots. However, the Veteran served in 1981 and 1982. The examiner opined it was at least as likely as not the bilateral foot disorder incurred in or caused by service, finding that the Veteran’s peripheral neuropathy was related to her fibromyalgia. A review of the record showed fibromyalgia was diagnosed in 2011. The Veteran asserts her fibromyalgia pain occurred after her bilateral foot pain. Accordingly, remand is required to address the Veteran’s assertions. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and her representative. 2. Contact the Veteran and afford her the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and her representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of her bilateral foot disorder, to include peripheral neuropathy. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a bilateral foot disorder had onset in, or is otherwise related to, active military service. The examiner must specifically address the following: 1) the Veteran’s assertions of in-service onset of bilateral foot pain; 2) the Veteran’s assertions that the bilateral foot pain began before her fibromyalgia; and 3) the VA examination report. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of her migraine headaches. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the migraine headaches had onset in, or are otherwise related to, active military service. The examiner must specifically address the following: 1) a headache complaint contained in the Veteran’s STRs, and 4) the Veteran’s assertions of in-service onset of migraine headaches. 5. Notify the Veteran that it is her responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655. In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 6. Ensure compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Bruton, Associate Counsel