Citation Nr: 21001355 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 11-08 149 DATE: January 7, 2021 ORDER Service connection for bilateral hearing loss is denied. Service connection for tinnitus is granted. Service connection for right hand arthritis is denied. A rating in excess of 10 percent for left finger fracture is denied. REMANDED Entitlement to service connection for pseudofolliculitis barbae (PFB) is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for pyrosis is remanded. Entitlement to service connection for headaches is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, a current disability of bilateral hearing loss for VA purposes. 2. The evidence is at least in equipoise as to whether the Veteran’s current tinnitus is related to his active service. 3. The Veteran’s right-hand disability is not secondary to his service-connected left finger disability and is not otherwise related to an in-service injury or disease. 4. The highest possible evaluation for limitation of motion of the left finger has been in effect for the entire period on appeal without evidence of ankylosis. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1111, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 2. The criteria for entitlement to service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a). 3. The criteria for service connection for a right-hand disability due to service or a service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for a rating in excess of 10 percent for the left finger fracture are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.71a, Code 5225. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1982 to August 1992. These matters are before the Board of Veterans’ Appeals (Board) on appeal from January 2010 and February 2012 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2017, the Veteran testified before the undersigned Veterans Law Judge via videoconference. In November 2017, the Board remanded the above matters for further development. As the requested development has not been completed as to the PFB, GERD, pyrosis, and headaches claims, the matter must be remanded again to ensure compliance with the remand directive is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Procedurally, the November 2017 Board decision also remanded the claims of service connection for erectile dysfunction, gout, lumbar spine, insomnia, bilateral shoulders, bilateral knees, and coccyx injury. These claims were granted in full in a July 2020 rating decision. As such, they are no longer within the Board’s jurisdiction. Moreover, the Board remanded the claims of service connection for posttraumatic stress disorder, wisdom teeth and upper and lower gum surgery, Chilblains disorder, and Raynaud’s disease, and an increased rating claim for major depression with alcohol use disorder. These claims were adjudicated by a subsequent and separate October 2020 Board decision after an October 2018 hearing with a different Veterans Law Judge. And, the Board also remanded the claim of service connection for hyperuricemia, which remains in development by the RO. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Where the Veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but an award solely on this basis is only permissible if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for hearing loss may be granted where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). Hensley v. Brown, 5 Vet. App. 155, 159 (1993). For purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 (Hz) is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). 1. Entitlement to service connection for bilateral hearing loss The Veteran contends that his bilateral hearing loss is a result of in-service noise exposure. The Veteran testified that he noticed hearing loss during active service. See April 2017 Board hearing transcript at page 15. He served in the signal unit and was exposed to generator noise and other loud-sounding equipment, and refueled helicopters that exposed him to aircraft noise. Id. The Veteran continued to experience hearing loss. He was also exposed to noise from firing weapons during military maneuvers and his six-month deployment during Operation Desert Storm. See 12/24/16 Correspondence The Board notes that service connection may not be granted in the absence of a current disability shown at some time during the claims period. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The clinical record fails to demonstrate a current bilateral hearing loss disability. A November 2017 Board decision noted the Veteran’s report of being exposed to loud generator and aircraft noises, the service treatment records suggesting a possible loss in hearing acuity between 1981 and 1984, as well as the May 1992 separation examination report not appearing to show hearing loss, as well as the insufficient evidence to determine whether the Veteran currently has bilateral hearing loss due to in-service noise exposure. The Board remanded the claim and directed the Agency of Original Jurisdiction (AOJ) to schedule the Veteran for a VA examination to determine etiology of any bilateral hearing loss disability. 11/08/2017, Remand BVA. In November 2019, the Veteran was afforded a VA audiological evaluation. The examiner recorded the following pure tone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 15 15 LEFT 10 10 15 15 10 Speech audiometry revealed speech recognition ability of 100 percent in the right ear, and 100 percent in the left ear. The audiological examination did not result in findings that qualified for bilateral hearing loss for VA purposes. 11/12/2019, C&P Exam. The Board recognizes the Veteran’s belief that he has a bilateral hearing loss disability due to his active service. In this regard, in Jandreau v. Nicholson, 492 F.3d. 1372, 1377 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient is an issue of fact. In this case, the lay evidence is insufficient to establish a diagnosis of bilateral hearing loss, as none of the factors set forth above have been satisfied. While the Veteran is competent to report observable symptoms such as decreased/difficulty hearing, he is not competent to conduct audiological testing to show a current disability. Moreover, the question of whether symptoms are representative of a diagnosis is a medical question requiring medical expertise. As such, the Veteran’s assertions cannot establish the element of current disability because they are not competent and lack weight. At no time during the appeal period has the Veteran’s hearing met the standards of 38 C.F.R. § 3.385. The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328 (1997). The Veteran does not have bilateral hearing loss as defined by 38 C.F.R. § 3.385, service connection cannot be granted. As the preponderance of the evidence weighs against a finding for service connection for the bilateral hearing loss disability claim, the benefit-of-the-doubt rule has been considered but the weight of the evidence is against the claim. 38 C.F.R. § 3.102.   2. Entitlement to service connection for tinnitus. The Veteran contends that his tinnitus is a result of in-service noise exposure. A November 2017 Board decision found insufficient evidence to determine whether the Veteran currently has tinnitus due to in-service noise exposure. The Board remanded the claim and directed the AOJ to schedule the Veteran for a VA examination to determine etiology of any tinnitus disability. 11/08/2017, Remand BVA. A November 2019 VA examination diagnosed the Veteran with tinnitus. The examiner also opined that the Veteran’s tinnitus is less likely than not related to the Veteran’s active duty service. Specifically, the examiner found that, because there was no evidence of significant change in hearing was documented from entry and release form active duty, there is no evidence of acoustic trauma to establish that tinnitus is related to military noise exposure. 11/12/2019, C&P Exam. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331, 1336-38 (Fed. Cir. 2013) (stating that the theory of continuity of symptomatology can be applied only in cases involving those connections explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Tinnitus is considered chronic as an “organic disease of the nervous system” under 38 C.F.R. § 3.309 (a). Fountain v. McDonald, 27 Vet. App. 258, 271 (2015) (holding the 38 C.F.R. “§ 3.309(a) includes tinnitus, at a minimum where there is evidence of acoustic trauma, as an ‘organic disease of the nervous system’”). Where the evidence shows “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. With chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). During an April 2017 Board hearing, the Veteran testified that he had been experiencing tinnitus symptoms during active service, and that he has been experiencing tinnitus symptoms continuously thereafter. 04/12/2017, Hearing Transcript, page 16. Likewise, the November 2019 VA examination indicates that the onset of his tinnitus occurred in 1991, during the Veteran’s period of active duty service, and that he has been experiencing symptoms continuously thereafter. 11/12/2019, C&P Exam Here, the competent and probative evidence of record is at least in equipoise as to whether that symptoms related to tinnitus manifested to a compensable degree during service. Therefore, the Board finds that the evidence shows that Veteran’s tinnitus is related to hazardous noise exposure while in service, and that his tinnitus began during service and has continued since then. 38 C.F.R. §§ 3.303(b), 3.309(a). As such, the Board finds that service connection for tinnitus is warranted. 3. Entitlement to service connection for right hand arthritis. The Veteran contends that his right-hand arthritis is proximately due to or aggravated by his service-connected left-hand disability. Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). A November 2017 Board decision noted September 2011 x-ray images showing calcific densities of the middle finger possibly due to an old injury, as well as a May 2012 diagnosis of right-hand carpal tunnel syndrome. See 07/07/2015, CAPRI, page 6; see also 03/26/2015, CAPRI, page 154. The Board remanded the issue and directed the AOJ to schedule the Veteran for a VA examination to determine etiology of any right-hand disability, to include an opinion as to whether the right-hand condition is due to the Veteran’s service-connected left-hand disability. 11/08/2017, Remand BVA. A December 2018 VA examination noted a diagnosis of bilateral index finger fracture. The Veteran denied injury or trauma to his right hand and wrist during his period of active service. The examiner opined that the Veteran’s right-hand disability is less likely than not proximately due to or aggravated by his service-connected left-hand disability. The examiner indicated that the Veteran’s right-hand functions totally independently of his left hand. And, even if the Veteran used his right hand more, which he undoubtedly would, as he is right hand dominant, the examiner unequivocally indicated that there is no connection whatsoever to his left-hand injury. 12/07/2018, C&P Exam. Likewise, the examiner also opined that the Veteran’s right-hand condition is less likely than not related to his active service, noting that the Veteran did not injure his right-hand during service and the Veteran had a history of right-hand injury while working in the post office. 10/28/2019, C&P Exam; see also 01/25/2012, CAPRI, page 17. An October 2019 VA examination noted a diagnosis of right hand, first metacarpal, trapezium articulation with mild degenerative change. This diagnosis is related to his right index finger fracture. The examiner opined that the Veteran’s right-hand disability is less likely than not proximately due to or aggravated by his service-connected left-hand disability. The examiner indicated that the function of the Veteran’s right hand is mostly independent from the function of his left hand. 10/28/2019, C&P Exam; 05/14/2020, C&P Exam (medical opinion) Based on the above, the Board concludes that, while the Veteran had a current right-hand disability, the preponderance of the evidence is against finding that the Veteran’s right-hand disability was proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Likewise, the preponderance of the evidence is against finding that the Veteran’s right-hand disability is related to his period of active service. Rather, the evidence establishes that the Veteran’s right-hand disability was related to his history of right-hand injury while working in the post office in 2011. Additionally, the Veteran denies injury or trauma to his right hand during active service. The Veteran believes that his right-hand disability was proximately due to or the result of his service-connected left-hand disability. The Veteran in this case was not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships. Therefore, it was outside the competence of the Veteran (or the appellant) in this case because the record does not show that either of them has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). As such, their statements regarding etiology are not competent and lack weight. Consequently, the Board gives more probative weight to the December 2018 and October 2019 VA examinations and medical opinions, which show adequate consideration of the relevant evidence and were provided by competent medical professionals. Therefore, the preponderance of the evidence is against the claim and service connection is denied. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). With regard to the issues at hand, as an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. The Veteran is competent to report symptoms observable by sense and contemporaneous medical diagnoses, but not competent to diagnose or assess the etiology of complex medical disorders. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 4. Entitlement to a rating in excess of 10 percent for left finger fracture. The Veteran contends that he is entitled to a rating in excess of 10 percent for left finger fracture, currently evaluated under Diagnostic Codes 5010-5229. The residuals of the fracture of the Veteran’s left index finger have been evaluated under the rating code for ankylosis of individual digits. Under these criteria, a 10 percent rating is assigned for favorable or unfavorable ankylosis of the index finger. 38 C.F.R. § 4.71a, Code 5225. The rating criteria for degenerative arthritis (Code 5003) instructs that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Code 5003. In addition, the Veteran’s left index finger is evaluated under the rating code for limitation of motion of the index or long finger. Under these criteria, a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or with extension limited by more than 30 degrees, a 10 percent rating is assigned. With a gap of less than one inch, or when extension is limited by no more than 30 degrees, a zero percent rating is warranted. 38 C.F.R. § 4.71a, Code 5229. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. A November 2017 Board decision noted that the Veteran had submitted a signed request for VA to obtain records of treatment for his hand in December 2011 at the Eastside Rehab Medicine and Pain Clinic in El Paso. The Board remanded the claim and directed the AOJ to obtain the aforementioned records, to include informing the Veteran what records could not be obtained, the efforts made to obtain the records, and what further action would be taken on his claims. 11/08/2017, Remand BVA. In March 2018, the AOJ sent a request to the Veteran to provide authorization for VA to obtain relevant private treatment records, to include records from Eastside Rehab Medicine and Pain Clinic in El Paso. 03/21/2018, Subsequent Development Letter. The Veteran provided authorization for the aforementioned records in April 2018, and subsequently provided another authorization in August 2018 with a valid signature and date. 04/02/2018, VA 21-4142; 04/06/2018, Correspondence; 08/15/2018, Subsequent Development Letter; 08/23/2018, VA 21-4142. In August 2018, the AOJ notified the Veteran that a request had been made to obtain treatment records from Eastside Rehab Medicine and Pain Clinic in El Paso. Nonetheless, the Veteran notified VA in April 2018 that the records from Eastside Rehab Medicine and Pain Clinic in El Paso had been destroyed. 04/02/2018, Correspondence. Additional private treatment records were received, which reveal that the Veteran is diagnosed with bilateral carpal tunnel and left basilar thumb. 04/23/2018, Medical Treatment Record – Non-Government Facility; 09/06/2018, Medical Treatment Record – Non-Government Facility, page 7. And, the Veteran reported numbness in both hands. 09/10/2018, Medical Treatment Record – Non-Government Facility, page 5. However, these records do not reference any treatment specifically for the Veteran’s service-connected left index finger. A September 2018 VA examination noted a diagnosis of status-post left index finger fracture. However, on examination the Veteran did not experience pain, and the range of motion of the index finger and long finger were both normal without a gap between the pad of the thumb or transverse crease and the fingers. There was no objective evidence of localized tenderness or pain on palpation of the joints and with passive range of motion testing of the left hand. Repetitive motion testing did not result in any additional functional loss. The examination was not conducted immediately after repetitive use over time nor during a flareup, and the examiner was unable to determine whether pain, weakness, fatigability and incoordination significantly limit functional ability without resort to speculation. Strength testing showed that hand grip was 5/5 in the left hand. There was no ankylosis. The examiner opined that the Veteran’s disability does not impacted his ability to perform occupational tasks. 09/25/2018, C&P Exam. The Board finds that a disability rating in excess of 10 percent for status post left finger fracture is not warranted. The Board acknowledges that the September 2018 did not describe functional loss after repetitive use over time or during a flareup in terms of limitation of motion. However, the 10 percent rating is the highest possible for limitation of motion of the index finger. Additionally, a higher rating is not possible under the rating criteria for ankylosis, as no evidence of ankylosis was shown on the September 2018 VA examination, and 10 percent is the highest rating for ankylosis of an individual digit (index finger). Further, the Board acknowledges that the Veteran’s diagnoses of carpal tunnel and left basilar thumb. And, although a higher rating is possible under the rating criteria for arthritis, the record is devoid of X-ray evidence of involvement of two or more major joints or two or more minor joint groups involving the service-connected left index finger. The Board concludes that the 10 percent rating is the highest that can be assigned for the left index finger under the facts of this case. 38 C.F.R. §§ 4.40, 4.45, 4.71a, Codes 5223, 5225, 5226, 5229. REASONS FOR REMAND 5. Entitlement to service connection for PFB is remanded. A November 2017 Board decision remanded the claim of service connection for PFB and directed the AOJ to schedule the Veteran for a VA examination to determine etiology of any PFB disability. 11/08/2017, Remand BVA. An October 2019 VA examination noted that the Veteran’s PFB had resolved and no longer requires treatment. 10/28/2019, C&P Exam. However, it is unclear if the Veteran has had a diagnosed PFB disability since his filed his service connection claim in 2010. The Board is cognizant of McClain v. Nicholson, 21 Vet. App. 319 (2007), in which the Court held that the requirement that a claimant have a current disability before service connection may be awarded for that disability is also satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present at the time of the claim’s adjudication. As such, the Board finds that an addendum opinion is needed to determine whether, at any time during the appeal period, a valid diagnosis of PFB was rendered and, if so, whether any disorder is at least as likely as not due to the Veteran’s active service. See McClain, 21 Vet. App. at 321; see also Romanowsky v. Shinseki, 26 Vet. App. 303 (2013) (stating that where a disease or disability is diagnosed proximate to the current appeal period, but not currently, the Board is required to determine whether the earlier diagnosis was inaccurate or the previously diagnosed condition had gone into remission). 6. Entitlement to service connection for GERD is remanded. 7. Entitlement to service connection for pyrosis is remanded. A November 2017 Board decision remanded the claims of service connection for GERD and pyrosis and directed the AOJ to schedule the Veteran for a VA examination to determine etiology of any gastrointestinal disability. 11/08/2017, Remand BVA. An October 2019 VA examination noted a diagnosis of GERD and associated symptoms of pyrosis. The examiner opined that the Veteran’s GERD and pyrosis is less likely than not related to the Veteran’s active duty service. The examiner merely indicated that the Veteran did not have documented symptoms, treatment, or diagnosis of GERD and pyrosis until 2010. 10/28/2019, C&P Exam; 10/28/2019, C&P Exam (medical opinion). However, the October 2014 Persian Gulf War Registry report includes the Veteran’s complaints of stomach problems that started in the Persian Gulf and continued. 10/18/1994, VA Examination. And, daily hiccups he attributed to heartburn were reportedly occurring since at least 2008. 03/26/2015, CAPRI, page 224. As such, the Board finds that the remand directives were not substantially complied with and, therefore, another remand is warranted. Stegall, 11 Vet. App. at 271. Specifically, the October 2019 VA examination erroneously found that the Veteran did not have documented symptoms, treatment, or diagnosis of GERD and pyrosis until 2010 and relied on incorrect premise in reaching the medical opinion. Based on the foregoing, the Board finds the October 2019 VA examination to be incomplete and a new examination is needed before a merits adjudication. 8. Entitlement to service connection for headaches is remanded. A November 2017 Board decision remanded the claims of service connection for headaches and directed the AOJ to schedule the Veteran for a VA examination to determine etiology of any headache disability, to include an opinion as to whether the headaches condition is due to the Veteran’s service-connected disabilities. 11/08/2017, Remand BVA. An October 2019 VA examination indicated that the Veteran is not diagnosed with a headache condition. However, the examiner noted the Veteran’s reports of chronic headaches occurring once or twice a month with a duration of 30 minutes to an hour. Further, the examiner’s opinion was based on the lack of documented treatment of chronic headaches. 10/28/2019, C&P Exam; 10/28/2019, C&P Exam (medical opinion). However, the treatment records reveal that the Veteran reported having headaches in October 1992. 09/23/2015, Medical Treatment Record – Government Facility, page 21. A December 2004 VA examination noted the Veteran’s reports of having headaches during active service. 12/09/2004, VA Examination, page 4. Additionally, the Veteran documented of having complained of headaches in May 2009. 05/27/2009, Medical Treatment Record – Non-Government Facility, page 1. And, an October 2010 VA examination noted that the Veteran had morning headaches twice every two weeks. 10/20/2010, VA Examination, page 3. As such, the Board finds that the remand directives were not substantially complied with and, therefore, another remand is warranted. Stegall, 11 Vet. App. at 271. Specifically, the October 2019 VA examination erroneously found that the Veteran did not have documented treatment of chronic headache and relied on incorrect premise in reaching the medical opinion. Based on the foregoing, the Board finds the October 2019 VA examination to be incomplete and a new examination is needed before a merits adjudication. These matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. Additionally, request the Veteran to submit any relevant private treatment reports or provide VA with authorization to obtain any such records. 2. After completing directive # 1, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any pseudofolliculitis barbae (PFB) condition present at any time since 2009. The examiner is asked the review the claims file to become familiar with the relevant medical history related to the Veteran’s PFB, to include obtaining a full history from the Veteran. The examiner is to address: (a.) For any current diagnosis of a PFB condition or any PFB condition present at any time since 2009, is it at least as likely as not (probability of 50 percent or more) related to an event, disease, or injury in service. The examiner is asked to provide a comprehensive rationale for any opinion offered. The examiner must consider lay reports from the Veteran. If the examiner cannot offer an opinion without resort to speculation, he or she should explain why and state what additional evidence, if any, would be required to offer an opinion. 3. After completing directive # 1, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any GERD and/or pyrosis condition. The examiner is asked the review the claims file to become familiar with the relevant medical history related to the Veteran’s GERD and/or pyrosis, to include obtaining a full history from the Veteran. The examiner is to address: (a.) For any current diagnosis of gastrointestinal disorder, including GERD, pyrosis, or another disorder (other than IBS and present at any time since 2009), is it at least as likely as not caused by a disease or injury in active service including the notations in the July 1991 service treatment records (noting complaints of diarrhea). The examiner is asked to provide a comprehensive rationale for any opinion offered. The examiner must consider lay reports from the Veteran. If the examiner cannot offer an opinion without resort to speculation, he or she should explain why and state what additional evidence, if any, would be required to offer an opinion. 4. After completing directive # 1, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any headache condition. The examiner is asked the review the claims file to become familiar with the relevant medical history related to the Veteran’s headaches, to include obtaining a full history from the Veteran. The examiner is to address: (a.) For any current diagnosis of a chronic headache condition, is it at least as likely as not caused by a disease or injury in active service, or had its onset in such service. (b.) For any current diagnosis of a chronic headache condition, is it at least as likely as not due to a service-connected disability, to include hypertension with costochondritis, sleep apnea, or major depressive disorder. (c.) For any current diagnosis of a chronic headache condition, is it at least as likely as not aggravated by a service-connected disability, to include hypertension with costochondritis, sleep apnea, or major depressive disorder disability? If aggravated, is there medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline of chronic headache disability prior to aggravation? The examiner is asked to provide a comprehensive rationale for any opinion offered. The examiner must consider lay reports from the Veteran. If the examiner cannot offer an opinion without resort to speculation, he or she should explain why and state what additional evidence, if any, would be required to offer an opinion. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David Han 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.