Citation Nr: 18155660 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-56 534 DATE: December 4, 2018 REMANDED Entitlement to service connection for a kidney disability is remanded. Entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1990 to August 1999. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision by the Department of Veterans Affairs (VA). The issue of entitlement to service connection for ovary removal was not appealed in the Veteran’s November 2016 substantive appeal (VA Form 9). Thus, that issue is not before the Board. The Veteran requested a Board hearing for the issues appealed in a November 2016 statement of the case (SOC), to include entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder and entitlement to a rating in excess of 50 percent disabling for bilateral plantar fasciitis, amongst others. See November 2016 VA Form 9. Because a Board hearing has not yet been conducted, the Board cannot take jurisdiction of those issues at this time. They will be the subject of a future Board decision. 1. Entitlement to service connection for a kidney disability is remanded. VA treatment records indicate the Veteran has stage two chronic kidney disease. See, e.g., May 2014 VA treatment records. The Veteran stated she believes she suffered kidney damage due to her preeclampsia during service, during which she had protein in her urine. See March 2016 notice of disagreement. She submitted several medical articles in support of her statement. See November 2016 correspondence. Because there are outstanding medical questions remaining, remand for a VA examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Entitlement to service connection for migraine headaches is remanded. The Veteran stated that her migraines began in service and that she was told by physicians that she could have been having cluster headaches or tension headaches. Her headaches have continued since that time. See March 2016 NOD. As noted by the Veteran, January 1992 service treatment records (STRs) reflect a complaint of headaches for two weeks, although her diagnosis at the time was a possible viral syndrome. See October 2016 VA Form 9; January 1992 STRs. A January 2016 VA examiner opined that the Veteran’s migraines were less likely than not caused by her service-connected posttraumatic stress disorder (PTSD), but did not consider aggravation. Additionally, by stating that the Veteran’s migraines were related to meningitis, the examiner relied on a possibly inaccurate premise, as medical records appear to state that meningitis was eventually ruled out. See March 2016 government treatment records. Thus, that opinion is inadequate, and remand for a new VA examination to obtain an opinion regarding direct and secondary service connection is necessary. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records from February 2017 to the present. 2. After the above development is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any kidney disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all kidney disabilities present during the appeal period (from December 2015). (b.) For each kidney disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s military service? Please explain why. The examiner must discuss the Veteran’s preeclampsia during service and the medical articles submitted in support of her statements. 3. After the development in the first instruction is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of her migraine headaches. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Is it at least as likely as not (50% or greater probability) that the Veteran’s migraine headaches were either caused or aggravated by her service-connected PTSD? Please explain why. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. (b.) Is it at least as likely as not (50% or greater probability) that the Veteran’s migraine headaches were either incurred in or otherwise related to the Veteran’s active duty service? Please explain why. The examiner must discuss the Veteran’s statement that her headaches began in and continued since service, and January 1992 STRs noting headaches but diagnosing possible viral syndrome. 4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Sandler, Associate Counsel