Citation Nr: 21000402 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 13-21 809A DATE: January 5, 2021 REMANDED Entitlement to service connection for dizzy spells is remanded. Entitlement to an increased evaluation in excess of 10 percent for myofascial headaches for the period prior to July 26, 2019, is remanded. Entitlement to an increased evaluation in excess of 30 percent for myofascial headaches for the period beginning July 26, 2019, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served in active duty service with the Army from February 1969 to February 1971. This matter is on appeal from an April 2011 rating decision. The Veteran was afforded an August 2016 hearing before the undersigned Judge. A transcript of the hearing has been associated with the claims record. The Board remanded this appeal in February 2017 and September 2020 for additional development. The Board finds that remand is warranted for additional development. In the September 2020 Board decision, the Board remanded for an addendum opinion to address evidence and testimony regarding the etiology of the Veteran’s claimed dizzy spells and whether they were a manifested symptom of the Veteran’s service-connected myofascial headaches or considered a separate condition. In October 2020 an addendum VA medical opinion was obtained. The VA examiner after review of the Veteran’s claims record and medical textbooks found that the Veteran’s claimed dizzy spells should not be considered a manifestation of the Veteran’s service-connected myofascial headaches. The examiner stated that medical textbooks found that “dizziness is not mentioned as one of the symptoms of myofascial headache” and the Veteran had experienced dizziness without headaches. The examiner opined that the Veteran’s dizzy spells were less likely as not related to the Veteran’s active duty service. The examiner found they were unable to locate any documented evidence of dizziness or its treatment during service or in the Veteran’s medical treatment record immediately after leaving service. However, the Board finds it is unclear whether the October 2020 VA examiner identified a underlying disease or condition that is responsible for the Veteran’s dizziness, as medical treatment records also show the Veteran with a history of hypertension and alcoholism with reports of feeling dizzy when trying to stop drinking. The Board notes that at a March 2011 VA examination the VA examiner found the Veteran’s reported dizziness as a symptom of the Veteran’s service-connected headaches. The Veteran also reported that he used to be an alcoholic and would get dizzy when trying to stop drinking; the Veteran described that after he stopped drinking, he began experiencing on and off dizzy spells to include getting dizzy before suffering headaches. The October 2020 VA examiner did not address or discuss this conflicting finding in making their opinion. As such, the Board finds the opinion inadequate and remand warranted to determine whether the Veteran has a current disability other than myofascial headaches characterized by dizziness or dizzy spells and, if so, whether such condition is related to service. Because a decision on the remanded issue of service connection for dizzy spells could significantly impact a decision on the issues of an increased evaluation for myofascial headaches and TDIU, these issues are inextricably intertwined. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Return the claims file to the VA examiner who provided the October 2020 opinion, if available, for an addendum opinion. The need for another examination is left to the discretion of the examiner providing the opinion. The Veteran’s claims file should also be made available to and be reviewed by the reviewing clinician. In completing this examination, the examiner is asked to respond to the following: (a.) The examiner is requested to identify, if possible, the underlying disease or disability causing the Veteran’s dizzy spells. The examiner should address and resolve the conflicting findings made by the March 2011 VA examination. (b.) The examiner should then provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the underlying cause of the Veteran’s dizziness/vertigo had its onset in service or is otherwise related to an event in service. (c.) The examiner is also advised that the Veteran is competent to report in-service events and treatment, and his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. (d.) A complete rationale for all opinions expressed should be provided. 3. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Yang, Attorney-Advisor The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.