Citation Nr: 18149398 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 15-45 617 DATE: November 9, 2018 REMANDED 1. The issue of entitlement to a rating in excess of 10 percent prior to December 15, 2017, and in excess of 30 percent thereafter for posttraumatic stress disorder (PTSD) is remanded. 2. The issue of entitlement to service connection for migraines is remanded. 3. The issue of entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2000 to April 2001, January 2008 to January 2009, and March to September 2010. He has additional periods of service in the Army National Guard. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In June 2017 and April 2018, the Board remanded the claims for additional development.   Increased Rating for PTSD The Board finds that a December 2017 Disability Benefit Questionnaire (DBQ) examiner’s report is inadequate for rating purposes based on the examiner’s incomplete responses. The December 2017 DBQ examiner acknowledged that she “left blank,” or omitted, some of the Veteran’s reported psychiatric symptoms in the DBQ report because she was unable to “expressly . . . link [them] to [the Veteran’s service-connected PTSD].” At this point, it is unclear whether the December 2017 DBQ report sufficiently reflects the current severity of the Veteran’s PTSD for an informed evaluation, given that the omitted psychiatric symptoms may have potentially contained favorable findings resulting in a higher rating for the Veteran’s service-connected PTSD. A remand is necessary to afford the Veteran a new VA examination to determine the current nature and severity for the Veteran’s PTSD symptoms. Service Connection for Migraines The Veteran contends that he has migraines due to service. He has also contended that the claimed migraines were caused or aggravated by his service-connected PTSD. See December 2015 Statement. A September 2000 enlistment examination report contains normal findings pertinent to the claimed migraines. Subsequent service treatment records contain reports of headaches. See February 2001 service treatment record (reporting headaches while reading); March 2001 service treatment record (noting an assessment of migraine headaches). The March 2001 service treatment record reflects that the Veteran reported experiencing migraines since the age of eleven. Of record are negative nexus opinions dated in March 2014, December 2017, and April 2018. None are responsive to the correct legal criteria based on the clinical evidence of preexisting migraines, see March 2001 service treatment record, which were not noted in the Veteran’s September 2000 enlistment examination report. The presumption of soundness attaches, which may be rebutted only by clear and unmistakable evidence (i.e. undebatable evidence) that the Veteran’s migraines were both pre-existing and were not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.304 (b) (2017). Further, while the April 2018 VA examiner rendered a negative secondary basis opinion based on the Veteran’s service-connected PTSD, reasoning that migraines and PTSD were “independent and separate and co-existing conditions,” the examiner did not address the December 2017 DBQ examiner’s affirmative response in the DBQ report that the Veteran’s “[a]nxiety [and] PTSD” were pertinent complications, conditions, signs, or symptoms related to the claimed migraines. It is also unclear whether the April 2018 VA examiner considered competent reports from the Veteran and his friend that the Veteran’s headache symptoms often worsened in association with his PTSD symptoms. See December 2015 Statements from the Veteran and his friend. A remand is necessary for an addendum addressing these deficiencies. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Service Connection for Hypertension The Veteran contends that he has hypertension due to service. He has also contended that his hypertension “preexisted [his service and] was aggravated . . . [during] active duty service.” See March 2014 DBQ report. The Veteran’s service treatment records contain elevated blood pressure readings during service. See, e.g., November 2000 service treatment record (containing a blood pressure reading of 138/68); March 2001 service treatment record (containing a blood pressure of 146/61). As yet, none of the nexus opinions in the record is responsive to the correct legal criteria addressing the Veteran’s contention that he had hypertension prior to service. Given that the claimed hypertension was not noted in the Veteran’s September 2000 enlistment examination report, the presumption of soundness attaches, which may be rebutted only by clear and unmistakable evidence (i.e. undebatable evidence) that the Veteran’s hypertension was pre-existing and was not aggravated by service. Wagner, 370 F.3d at 1096; 38 C.F.R. § 3.304(b). A remand is necessary to obtain such an opinion. See Barr, 21 Vet. App. at 311. The matters are REMANDED for the following action: 1. Update private and VA clinical records of the Veteran. 2. Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of his service-connected PTSD. The record, to include a copy of this remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. Any indicated evaluations, studies, and tests should be conducted. All opinions expressed must be accompanied by supporting rationale. 3. Obtain a medical opinion from appropriate examiners addressing the Veteran’s service connection claims for migraines and hypertension. (A) The examiner should confirm diagnoses of migraines and hypertension present since the date of the claim (i.e. since November 2013). (B) The examiner should then opine whether there is clear and unmistakable evidence (i.e. undebatable evidence) that the claimed headaches and/or hypertension pre-existed the Veteran’s service. If so, the examiner should determine whether there is clear and unmistakable evidence (i.e. undebatable evidence) that the pre-existing headaches and/or hypertension did not undergo an increase in the underlying pathology during service, i.e., was not aggravated during service. (B) For migraines and hypertension, if there is no clear and unmistakable evidence that such disorder pre-existed service, then the examiner should opine whether it is at least as likely as not (a 50 percent probability or greater) that the disorder is directly related to service. (C) The examiner should also opine whether it is at least as likely as not (a 50 percent probability or greater) migraines were manifest to at least a compensable degree within one year of the Veteran’s discharge from his active duty service (periods ending in April 2001, January 2009, and September 2010). If so, the examiner should comment on the nature of those manifestations. (D) For migraines, the examiner should opine as to whether such was caused OR aggravated (beyond natural progression) by the Veteran’s service-connected PTSD. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation (specifying the baseline level of disability and current level of severity, based on consideration of VA’s rating schedule). In answering this question, the examiner should consider the competent reports from the Veteran and his friend that he experiences migraines symptoms in association with his PTSD symptoms. See December 2015 Statements. In offering the requested opinions, the examiner’s attention is specifically directed to the above-referenced service treatment records noting the Veteran’s reports of migraines and elevated blood pressure readings during his service. A complete rationale should be given for all opinions and conclusions expressed. 4. After completing the above, and any other development as may be indicated, the AOJ is to readjudicate the claims based on the entirety of the evidence of record. If the claims remain denied, the Veteran should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Kim, Associate Counsel