Citation Nr: 18154254 Decision Date: 11/30/18 Archive Date: 11/29/18 DOCKET NO. 16-55 348 DATE: November 30, 2018 REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a disorder characterized by headaches, to include as due to an undiagnosed illness and/or exposure to Gulf War environmental hazards, is remanded. REASONS FOR REMAND As to headaches, the Veteran contends that these were directly incurred in service or, alternatively, that they are the result of an undiagnosed illness and/or exposure to Gulf War environmental hazards. The Veteran’s DD-214 shows that he served in the Navy and that although he had no foreign service, he had more than three years of sea service; it also shows receipt of a Southwest Asia Service Medal. Receipt of such medal indicates that the Veteran’s service in Southwest Asia is potentially verified. See VA Adjudication Procedures Manual M21-1, Part IV, Subpart ii, Chapter 1, Section E.1.c. The Manual further advises that a veteran’s DD-214 and/or personnel records should be reviewed to ensure that this medal was not awarded solely for service in Israel, Egypt, Turkey, Syria, or Jordan (including the airspace above and the territorial waters) from January 17, 1991, through November 30, 1995. Id. In this case, although a July 2016 PIES response indicates that the Veteran’s personnel records are unavailable, there are at least some personnel records showing that the Veteran was aboard the USS Horne from August 1990 until discharge in December 1991 and that he received the Southwest Asia Service Medal for the period from January 1991 to April 20, 1991. The claims file also shows a July 2016 VA memorandum which includes a screenshot of a webpage from the U.S. Naval History and Heritage Command, an official U.S. Navy website, which shows that on December 7, 1990, the USS Horne departed for the Persian Gulf. As such, it appears that the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War and that he is a Persian Gulf Veteran. See 38 C.F.R. § 3.317(e)(2) (designating service in the Persian Gulf as qualifying as service in the Southwest Asia theater of operations). He therefore may be entitled to compensation for an undiagnosed illness or medically unexplained chronic multisymptom illness. 38 U.S.C. § 1117(a)(2)(A), (B); 38 C.F.R. § 3.317(a)(2)(A), (B) (2017). Significantly, signs or symptoms of such illness include, among other things, headache. 38 C.F.R. § 3.317(b)(3). Entitlement to compensation requires that the resulting disability manifest to a compensable degree and cannot be attributed to any known clinical diagnosis, and that the disability has existed for 6 months or more or exhibits intermittent episodes of improvement or worsening over a 6-month period. 38 C.F.R. § 3.317(a)(i), (ii), (4). Here, although service treatment records are negative for complaints of headaches, the Veteran is competent to report experiencing headaches and has stated that he began experiencing headaches during service and that they have continued since that time. See December 2012 correspondence; October 2013 VA treatment record. Although a VA etiological examination was obtained in March 2013, the examiner there did not consider the Veteran’s statement that he has experienced headaches since service and appears to have rejected the premise that the Veteran had qualifying service in Southwest Asia. Accordingly, an addendum opinion should be obtained. As to the low back, the Veteran contends that his current low back disabilities are related to a low back injury during service. (He does not appear to relate his back disorders to service in Southwest Asia.) Service treatment records show that he injured his back after lifting heavy boxes of frozen food. The Veteran is competent to report experiencing muscle and joint pain and has alleged that he has experienced back pain since service. See October 2013 VA treatment record. He has also submitted an opinion from a private treating doctor who opined that “it can be conjectured that injury of the L5 region occurred while lifting the box while in the military back in 1989.” See August 2014 private treatment record. Accordingly, an addendum to the March 2013 VA etiological opinion should be obtained which addresses the Veteran’s competent reports of back pain since service as well as the private opinion suggesting a link between the Veteran’s current back disorders and his military service. The matters are REMANDED for the following action: 1. Forward the entire claims file to the examiner who prepared the March 2013 VA opinions addressing the etiology of any current low back and headache disorder, or, if that examiner is unavailable, to another suitably qualified VA examiner. The claims file should be reviewed by the examiner. (a) Regarding headaches, the examiner should first indicate whether the Veteran experiences any headaches that have not been attributed to a known clinical diagnosis. If any such signs or symptoms cannot be attributed to a known clinic diagnosis, the examiner should indicate if the symptoms have persisted for 6 months or more. Then, as to any diagnosed headache disorder, the examiner should indicate whether it is at least as likely as not (50 percent probability or more) that such disorder is related to or had its onset during the Veteran’s military service. (b) Regarding the low back, the examiner should identify all current low back disorders. Then, for each diagnosed disorder, the examiner should indicate whether it is at least as likely as not (50 percent probability or more) that such disorder is related to or had its onset during the Veteran’s military service. The examiner is advised that the Veteran is competent to report symptoms and treatment and that his reports must be taken into account in formulating the requested opinion. A complete rationale should accompany any opinion provided. 2. If any benefit requested on appeal is not granted to the Veteran’s satisfaction, the appellant and his representative should be furnished a supplemental statement of the case and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Counsel