Citation Nr: 1807451 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 13-31 393 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for headaches, to include as secondary to service-connected tinnitus and posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Wisconsin Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD David Nelson, Counsel INTRODUCTION The Veteran had active service from March 1968 to February 1970, with service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. The Veteran appeared before the undersigned Veterans Law Judge in November 2016 and delivered testimony via video conference hearing in Wausau, Wisconsin. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Legacy Content Manager (LCM). LCM contains additional VA treatment records, but otherwise contains documents duplicative of what is in VBMS or irrelevant to the issue on appeal. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Remand is required to obtain an adequate examination. Although April 2011 and September 2013 VA examinations were, the opinions do not adequately address the theories of entitlement. The Veteran asserts his headaches are caused or aggravated by this service-connected PTSD and tinnitus. In particular, the April 2011 VA examiner's opinion did not address aggravation, and the September 2013 VA examiner supported an aggravation opinion with direct secondary service-connection, or causation, language. Additionally, at an April 2010 VA PTSD examination, it was noted that the Veteran's headaches were aggravated by medications used to treat his service-connected disabilities, and this aspect of the Veteran's claim has not been addressed by the medical opinions of record. Accordingly, the case is 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 on and after December 16, 2016. 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 his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant non-VA 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 appellant 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 his representative. 3. After any additional records are associated with the claims file, provide the Veteran with the appropriate examination to determine etiology of the headaches. 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 answer the following questions: a) is it as likely as not (a 50 percent probability or more) that headaches had onset in, or are otherwise related to, active service. b) is it as likely as not (a 50 percent probability or more) that headaches are caused by his service-connected tinnitus and/or PTSD. c) is it as likely as not (a 50 percent probability or more) that headaches are aggravated (worsened) by his service-connected disabilities, to include the service-connected tinnitus and/or PTSD and the medications used to treat the tinnitus and PTSD. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). 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. 5. Ensure compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. 6. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If any claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).