Citation Nr: 18150575 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-49 624 DATE: November 15, 2018 REMANDED The claim of entitlement to service connection for chronic headaches is remanded. The claim of entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder (MDD) and obsessive-compulsive disorder (OCD), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1999 to September 2002. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009), the claims for service connection for mental health disorders, previously separated, have now been combined herein to include any psychiatric disorder. In a December 2007 rating decision, the RO determined that service connection was not warranted for headaches or for mental health disorders. The Veteran was notified but did not submit a notice of disagreement (NOD) within one year. Years later, in 2014, when she filed to reopen the claims, the RO denied the claims as new and material evidence had not been submitted that was sufficient to reopen the claims. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2018). However, it is noted that previously existing service treatment records (STRs) that were unavailable at the time of the December 2007 rating decision were added to the claims file in November 2008. In this case, these STRs are pertinent to her claims for service connection for headaches and an acquired psychiatric disorder. Pursuant to 38 C.F.R. § 3.156(c), VA must reconsider the claims, notwithstanding the provisions of 38 C.F.R. § 3.156(a) which require the submission of new and material evidence to reopen a finally denied claim. The Board has also determined that VA examinations which adequately address the etiologies of the Veteran’s headaches and psychiatric disorder(s) have not been accomplished and should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain any missing VA treatment notes and associate them with the claims file. Moreover, invite the Veteran to identify any additional medical providers who treated her for headaches or for mental health disorders. After receiving this information and any necessary releases, contact the named medical providers and obtain copies of the related medical records which are not already in the claims folder. 2. Thereafter, schedule the Veteran for an appropriate VA examination for the purpose of ascertaining the nature and etiology of her headaches. The claims file must be made available to and pertinent documents therein reviewed by the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. The examiner is asked to address the following questions: a) With respect to headaches, is it clear and unmistakable (obvious, manifest, or undebatable) that such disorder existed prior to active military service? And if so, is it also clear and unmistakable (obvious, manifest, or undebatable) that chronic headaches were not aggravated during or by her active military service, that is, above and beyond the condition’s natural progression? Any clear and unmistakable (obvious, manifest, or undebatable) evidence which serves as the basis for any opinion must be specifically identified. b) In the event that it is not clear and unmistakable (obvious, manifest, or undebatable) that headaches either preexisted service or, if preexisting, were not aggravated by service, is it is at least as likely as not (50 percent probability or more) that such were incurred in or was caused by, or are otherwise related to, the Veteran’s active service. 3. Schedule the Veteran for an appropriate VA examination to address the claim for service connection for an acquired psychiatric disorder as secondary to headaches. The claims file must be made available to and pertinent documents therein reviewed by the examiner in conjunction with the claim. Any medically indicated tests should be accomplished and all pertinent symptomatology and findings must be reported in detail. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran has an acquired psychiatric disorder that is caused by his service-connected headache disorder? Please explain why or why not. b) If not directly caused by the headache disorder, does the Veteran have an acquired psychiatric disorder that is worsened beyond normal progression (versus temporary exacerbation) by the headache disability? Please explain why or why not. c) If the Veteran has an acquired psychiatric disability that is worsened beyond normal progression (aggravated) by the service-connected headaches, the examiner should attempt to define the baseline level of such disability and the degree of worsening of such disability that is attributable to the headache disorder. (CONTINUED ON NEXT PAGE) A rationale for the opinions expressed should be provided. BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Hal Smith