Citation Nr: 21003131 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 18-22 788 DATE: January 19, 2021 ORDER An effective date of June 4, 2014, and no earlier, for the award of service connection for radiculopathy, left upper extremity (LUE), is granted. As the appeal has been withdrawn, the claim of entitlement to an initial rating higher than 20 percent for thoracic spine degenerative disc disease (herein after back disability) is dismissed. As the appeal has been withdrawn, the claim of entitlement to a rating higher than 20 percent for cervical spine strain with intervertebral disc syndrome (herein after neck disability) is dismissed. As the appeal has been withdrawn, the claim of entitlement to an effective date earlier than November 17, 2015 for the award of service connection for headache disability is dismissed. As the appeal has been withdrawn, the claim of entitlement to an effective date earlier than November 17, 2015 for the award of service connection for back disability is dismissed. As the appeal has been withdrawn, the claim of entitlement to an effective date earlier than March 18, 2015 for the assignment of a 20 percent rating for neck disability is dismissed. REMANDED Entitlement to service connection for an acquired psychiatric disorder, other than depression, is remanded. Entitlement to an initial rating in excess of 30 percent for depression, secondary to neck disability, is remanded. Entitlement to an effective date earlier than March 17, 2017, for the grant of service connection for depression is remanded. Entitlement to a rating higher than 40 percent for radiculopathy, right upper extremity (RUE), from March 18, 2015 is remanded. Entitlement to a rating higher than 30 percent for radiculopathy, LUE, from March 18, 2015 is remanded. Entitlement to an initial compensable rating for migraine headache disability (herein after migraines) is remanded. FINDINGS OF FACT 1. Affording the Veteran the benefit of any doubt, VA received the Veteran’s informal claim on June 4, 2014 for service connection for neurologic disorder (now service-connected as radiculopathy) and as VA failed to provide the Veteran with the appropriate application form, the one-year period for filing a formal claim was never triggered and the informal claim is accepted as the application for purposes of establishing the effective date; however, there is no prior unadjudicated informal or formal claim for service connection for radiculopathy, to include any neurologic disorder. 2. In an August 2019 written statement, prior to the promulgation of a decision in the appeal, the appellant’s authorized representative requested a withdrawal of the issues of entitlement to (1) an initial rating higher than 20 percent for back disability, (2) a rating higher than 20 percent for neck disability, (3) an effective date earlier than November 17, 2015 for the award of service connection for migraines, (4) an effective date earlier than November 17, 2015 for the award of service connection for back disability, and (5) an effective date earlier than March 18, 2015 for the assignment of a 20 percent rating for neck disability. CONCLUSIONS OF LAW 1. The criteria for assignment of an effective date of June 4, 2014, and no earlier, for the award of service connection for radiculopathy, LUE, have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400(b)(2). 2. The criteria for withdrawal of the claim for entitlement to an initial rating higher than 20 percent for back disability by the appellant (or his or her authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 3. The criteria for withdrawal of the claim for entitlement to a rating higher than 20 percent for neck disability by the appellant (or his or her authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 4. The criteria for withdrawal of the claim for entitlement to an effective date earlier than November 17, 2015 for the award of service connection for migraines by the appellant (or his or her authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 5. The criteria for withdrawal of the claim for entitlement to an effective date earlier than November 17, 2015 for the award of service connection for back disability by the appellant (or his or her authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 6. The criteria for withdrawal of the claim for entitlement to an effective date earlier than March 18, 2015 for the assignment of a 20 percent rating for neck disability by the appellant (or his or her authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, served on active duty from February 1991 to May 1991, from April 1993 to April 1996, and from August 1997 to May 2006. He has had a combined schedular rating of 100 percent from November 17, 2015, and a total rating (100%) based on individual unemployability from March 18, 2015. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Board has recharacterized the Veteran’s May 2014 claim for PTSD more broadly as a claim for an acquired psychiatric disorder, to include PTSD, anxiety, and depression, to more broadly reflect that the Veteran seeks service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board observes that, in the Veteran’s June 2016 notice of disagreement, the Veteran’s representative requested an earlier effective date for the assignment of a 20 percent rating for radiculopathy, RUE. To the extent that the Veteran seeks to establish an earlier effective date for this disability’s current rating, which was assigned in a December 2006 rating decision, he is advised that all claims for benefits must be submitted on required forms. Effective on March 24, 2015, VA amended its rules as to what constitutes a claim for benefits; such now requires that claims be made on specific claim form prescribed by the Secretary and available online or at the local Regional Office. This provision effectively removed informal claims from VA’s processes. Although the Veteran requested a hearing with the Board, the Veteran’s representative has since expressed to VA in writing the intention to withdrawal the requested Board hearing. See Third Party Correspondence (September 2018). Since the withdrawal request was received prior to the scheduled hearing date, the Board finds that the hearing request has been withdrawn. 38 C.F.R. § 20.704(e). In an August 2018 statement of the case, the RO assigned a 40 percent rating for radiculopathy, RUE, effective March 18, 2015, and assigned an initial 30 percent rating for radiculopathy, LUE, effective March 18, 2015. As higher evaluations are available under the rating schedule, these claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that Veterans are presumed to seek the maximum available benefit for a disability). In January 2019, the Board remanded the claim of entitlement to service connection for obstructive sleep apnea for additional evidentiary development. During remand status, the RO granted service connection for obstructive sleep apnea, to include chronic obstructive pulmonary disease (COPD) and, hence, there remains no controversy for the Board’s consideration as to these matters. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). Earlier Effective Dates Generally, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). The effective date of awards of claims granted on a secondary basis can be no earlier than the date of the claim for compensation on a secondary basis. See Ellington v. Nicholson, 22 Vet. App. 141, 145 (2007) (finding that the effective date for a grant of service connection for diabetes and hypertension as secondary to leukemia was the date of the claim for secondary service connection, not the date of the claim of service connection for leukemia), aff’d sub nom. Ellington v. Peake, 541 F.3d 1364 (Fed. Cir. 2008); Ross v. Peake, 21 Vet. App. 528, 532-33 (2008) (holding that the effective date for a grant of secondary service connection for depression with anxiety was the date of the secondary service connection claim, not the date of the claim for service connection for the primary heart condition). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 U.S.C. § 101(30); 38 C.F.R. § 3.1(p). The date of receipt shall be the date on which a claim, information, or evidence was received by VA. 38 U.S.C. § 101(30); 38 C.F.R. § 3.1(r). Any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claims must identify the benefit sought. 38 C.F.R. § 3.155. 1. Entitlement to an effective date prior to March 18, 2015, for the award of service connection for LUE radiculopathy. The Veteran’s representative contends that an effective date of May 21, 2014 for the award of service connection is warranted because the Veteran reported bilateral arm numbness during a telephonic appointment. Additionally, the Veteran’s representative contends that the law applicable to the effective dates for increased rating claims, 38 C.F.R. § 3.400(o)(2), applies as the Veteran had a pending claim for a total disability rating based on individual unemployability due to service-connected disability (TDIU) at the time of his May 21, 2014 report of arm numbness. See VA 646 Statement of Accredited Representative in Appealed Case (August 2019). The Board concludes that the evidence supports the assignment of an earlier effective date of June 4, 2014, and no earlier, for radiculopathy, LUE, as the effective date of the award of compensation based on an original claim is the date of receipt of the claim. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400(b)(2). The essential requirements of any claim, whether formal or informal, are: (1) an intent to apply for benefits, (2) an indication of the benefits sought, and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). In regard to the applicable law in 2014, a claim means “a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement, to a benefit.” 38 C.F.R. § 3.1(p) (2014). An indication of “an intent to apply for one or more benefits… may be considered an informal claim…” if such identifies the benefit sought. 38 C.F.R. § 3.155(a) (2014). “Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution.” Id. When VA fails to furnish the appropriate application form upon receipt of an informal claim, “the one-year period for filing a formal claim was never triggered….” Quarles v. Derwinski, 3 Vet. App. 129, 137 (1992). Here, VA treatment records from May 2014 show that the Veteran reported “bilateral numbness of 1st-3rd digits, plus entire arm… [and that it] occurs nearly daily, lasting for about 1 minute or so.” See CAPRI (April 2015). VA then received an informal claim on June 4, 2014, in which the Veteran expressed, in writing, a belief of entitlement to VA benefits for a neurologic disability. See VA 21-4142 Authorization for Release of Information (June 2014). The Veteran listed “Neurologic” as a disability for which he filed his current claim, and identified the VA Long Beach facility as the location of treatment. Id. A report of VA medical examination dated in July 2015 shows that bilateral incomplete paralysis of the middle radicular nerve group (upper extremity radiculopathy) is secondary to service-connected neck disability. As the June 2014 release of information was a communication in writing, that evidenced a belief of entitlement to benefits, and identified a neurologic disability, for which the medical evidence in possession of VA at the time showed complaints for (left arm numbness), the Board finds that communication to be sufficient for an informal claim which triggered VA’s duty to provide an application form. Browkowski v. Shinseki, 23 Vet. App. 79 (2009); see also 38 C.F.R. § 3.1(p) (2014); 38 C.F.R. § 3.155(a) (2014). However, as VA failed to provide the Veteran with the appropriate application form, “the one-year period for filing a formal claim was never triggered, and the informal claim must be accepted as the application for purposes of establishing the effective date under 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2).” Quarles, 3 Vet. App. at 137 (citing Kuo v. Derwinski, 2 Vet. App. 662 (60-day period for filing formal appeal to BVA “did not commence to run” where VA did not mail to appellant statement of the case (SOC), as required by law, because law specifies that 60-day period runs from mailing of SOC)). The Board has considered the Veteran’s representative’s contentions that an effective of May 21, 2014 is warranted. However, the Board finds that the evidence reflects no communication prior to the June 2014 release of information that may be construed as a claim as to this matter. VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed and the mere presence of medical evidence that a veteran suffers from a disability does not establish intent on the part of the veteran to seek service connection for that disability. See Brannon v. West, 12 Vet. App. 32, 35 (1998). See also, Brokowski, supra. Notably, the May 2014 complaint did not reference his service-connected disabilities or indicate in any way that he believed he was entitled to benefits for arm numbness. Id. Additionally, the provisions of 38 C.F.R. § 3.400(o)(2) regarding retroactive benefits “apply only when such reports relate to examination or treatment of a disability for which service-connection has previously been established.” 38 C.F.R. § 3.400(o)(2). As service-connection for radiculopathy, LUE, had not yet been established and the Veteran had no pending claim for an increased rating, to include TDIU, at the time of the Veteran’s report of arm numbness, the provisions of 38 C.F.R. § 3.400(o)(2) are inapplicable. Accordingly, the Board concludes that the evidence supports the assignment of an effective date of June 4, 2014, and no earlier, for radiculopathy, LUE, affording the Veteran the benefit of any doubt. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400(b)(2). 2. Entitlement to an initial rating higher than 20 percent for back disability. 3. Entitlement to a rating higher than 20 percent for neck disability. 4. Entitlement to an effective date earlier than November 17, 2015 for the award of service connection for migraines. 5. Entitlement to an effective date earlier than November 17, 2015 for the award of service connection for back disability. 6. Entitlement to an effective date earlier than March 18, 2015 for the assignment of a 20 percent rating for neck disability. Issues 2 – 6: The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In an August 2019 written statement, the appellant’s authorized representative requested a withdrawal of his appeal as to the issues of entitlement to (1) an initial rating higher than 20 percent for back disability, (2) a rating higher than 20 percent for neck disability, (3) an effective date earlier than November 17, 2015 for the award of service connection for headache disability, (4) an effective date earlier than November 17, 2015 for the award of service connection for back disability, and (5) an effective date earlier than March 18, 2015 for the assignment of a 20 percent rating for neck disability. See VA 646 Statement of Accredited Representative in Appealed Case (August 2019). That written notice contained the appellant’s name and claim number, and it was signed by the appellant’s authorized representative. It is clear and unambiguous. See DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). In the present case, the requirements for withdrawal are met. Hence, there remain no allegations of errors of fact or law for appellate consideration regarding the issues of entitlement to (1) an initial rating higher than 20 percent for back disability, (2) a rating higher than 20 percent for neck disability, (3) an effective date earlier than November 17, 2015 for the award of service connection for headache disability, (4) an effective date earlier than November 17, 2015 for the award of service connection for back disability, and (5) an effective date earlier than March 18, 2015 for the assignment of a 20 percent rating for neck disability. Accordingly, the Board does not have jurisdiction to review the appeal of those matters and the appeal of those matters is dismissed. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. 2. Entitlement to an initial rating in excess of 30 percent is remanded. 3. Entitlement to an effective date prior to March 17, 2017, for the award of service connection for depression is remanded. The Veteran contends that his psychiatric disorder, claimed as PTSD, began in-service during the Gulf War and particularly, after witnessing a military aircraft crash while he was assigned to an air defense artillery unit. See VA 21-0781, Statement in Support of Claim for PTSD (March 2009); VA 21-4138 Statement In Support of Claim (March 2009); NOD (July 2014). The Veteran’s representative, in August 2019 correspondence, indicated that his client sought a disability rating in excess of 30 percent for an acquired psychiatric disorder. He suggested that the Veteran had symptoms other than depression, such as persistent delusions or hallucinations based on an examiner’s report that the Veteran had auditory flashback and reported seeing frequent movement in his periphery and hearing his cam called or whispering. The representative further referenced the Veteran has having PTSD symptoms warranting the assignment of a higher disability rating. See VA Form 646 (August 2019). By way of procedural history, the record shows that service connection for PTSD was denied in February 2010, February 2011, and July 2014 rating decisions because, inter alia, the evidence failed to establish a diagnosis of PTSD during service or that the Veteran’s claimed stressor was related to his engagement in combat with the enemy, as required by 38 C.F.R. § 3.304(f). The Veteran has continually appealed the July 2014 rating decision via his July 2014 notice of disagreement and May 2015 appeal to the Board. Although a May 2017 rating decision granted service connection for PTSD with depression and alcohol abuse as secondary to service-connected disability, a March 2018 statement of the case (SOC) informed the Veteran that the May 2017 decision contained an error and that the correct grant of service connection was for depression secondary to service-connected neck disability. The March 2018 SOC also informed the Veteran that he has a separate appeal pending for service connection for PSTD, (recharacterized herein as any acquired psychiatric disorder). As to the substantive history, service treatment records document mental health symptoms. For example, a February 2000 mental health evaluation showed complaints of trouble falling asleep, losing weight, and lack of appetite; mood was concerned and angry; the assessment was phase of life issues with possible depressive component. A March 2001 STR reflects complaints of nervousness. A November 2001 STR reflects complaints of anxiety. A March 2006 STR reflects normal psychiatric evaluation on report of medical history for medical board purposes; however, the clinician noted symptoms of anxiousness. Post service, a July 2006 VA treatment records show that that the Veteran was assessed with an adjustment disorder with mixed anxiety and depressed mood. See Medical Treatment Record - Government Facility (November 2015). Similarly, Social Security Administration (SSA) records show depressive disorder, inter alia, as the Veteran’s “[p]robable DSM-IV diagnoses….” See Medical Treatment Records - Furnished by SSA (November 2016). An April 2017 VA PTSD examination (Disability Benefits Questionnaire) diagnosed the Veteran with PTSD under the DSM-V along with depression and alcohol abuse. This diagnosis was linked to the Veteran’s witnessing, in person, a traumatic event described as seeing a plane crash in Kuwait in 1999. The Veteran described the incident in more detail as follows: …he saw an airplane coming in swaying back and forth. The plane crashed on a berm and all passengers died. There was a colonel flying the plane. Claimant was told that this pilot was on his way to the Fort Leavenworth prison. Claimant had to pick up debris afterwards but not near the crash site. He was horrified because he saw this happening and there was nothing he could do to stop it. Later claimant began to dream about this incident. VA treatment records, to include those recently dated in 2019, reflect that the Veteran carries diagnoses for PTSD, major depressive disorder, and alcohol use disorder. These further reflect that he is prescribed Sertraline for his symptoms of PTSD and depression. Having reviewed the record, the Board concludes that remand is necessary for the following reasons. First, the originating agency’s announcement of a change in the scope of the grant of service connection from PTSD to the more narrowly tailored grant of depression via a March 2018 SOC is a due process violation. The change in the scope of the grant is a material change of the May 2017 rating decision that granted service connection for PTSD with depression and alcohol abuse (claimed a depression), and on which the notice of disagreement was filed as to the initial 30 percent rating assigned. See 38 C.F.R. § 19.29 (Statement of the Case). The record includes no rating decision addressing whether there was clear and unmistakable error in the May 2017 rating decision’s grant of service connection for PTSD with depression and alcohol abuse. Second, even if a veteran is already service connected for a disability of a body part or body system (such as an depression), service connection may also be available for an additional disorder of the same part or system, e.g. the psychiatric system, if the additional disorder has different symptoms from the service-connected disability. This has not been thoroughly addressed by the originating agency. Third, a medical opinion has not been obtained that adequate addresses the etiology of all the Veteran’s mental disorders shown during the appeal period, to include whether a disorder was first manifested during his active service or otherwise related to in-service injury or disease. 38 C.F.R. § 3.159(c)(4). Given the above, remand is necessary to afford the Veteran due process of law and to obtain a new VA psychiatric examination addressing the etiology of all disorders found during the appeal period and the severity of his service-connected mental disorders. Further, it is noted that the Board must defer consideration of the certified issue of entitlment to a rating in excess of 30 percent for depression along with an earlier effective date for the grant of service connection for depression, previously granted as PTSD. This is because these matters are inextricably intertwined with the claim for service connection for an acquired psychiatric disorder to include PTSD and anxiety. See Harris v. Derwinski, 1 Vet. App. 181 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). 4. Entitlement to a rating higher than 40 percent for radiculopathy, RUE, from March 18, 2015. 5. Entitlement to a rating higher than 30 percent for radiculopathy, LUE, from March 18, 2015. Issues 2 & 3: The Veteran’s representative contends that maximum ratings for bilateral radiculopathy are warranted based on the Veteran’s reports of flare-ups. See VA 646 Statement of Accredited Representative in Appealed Case (August 2019). The Board finds that remand is required as the medical evidence of record is inadequate to address the severity of the Veteran’s disabilities throughout the appeal period, given the Veteran’s continued assertions that his disabilities are more severely disabling than reflected in the current rating, in light of the amount of time since his last VA examination for radiculopathy, and the possible increase in severity since the last examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) (“Where the record does not adequately reveal the current state of the claimant’s disability... the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination.”). See also Caffrey v. Brown, 6 Vet. App. 377 (1994) (wherein the Court determined the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating). Additionally, the evidence indicates that there are outstanding private treatment records. In March 2018, VA records show that the Veteran was approved for non-VA treatment for upper extremity pain. Additionally, VA records from April 2018 show that the Veteran received treatment from Rehab Service on six occasions, from March 2018 to April 2018, for upper extremity pain. Further, VA records from January 2019 show that the Veteran received magnetic resonance imaging (MRI) at McLeod Regional Medical Center Imaging in January 2019. However, the claims file shows only private treatment records through November 2017. As the Veteran’s radiculopathy complaints include upper extremity pain, these records may be relevant in determining the severity of his disabilities. Accordingly, remand is required to ensure that VA has met its duty to assist. 38 C.F.R. § 3.159(c).   6. Entitlement to an initial compensable rating for migraines. The Veteran’s representative contends that a compensable rating is warranted based on subjective reports of pain, sensitivity to noise and light, nausea, visual disturbances, and objective reports of restricted activity due to migraines. See VA 646 Statement of Accredited Representative in Appealed Case (August 2019). The Board finds that remand is required as the medical evidence of record is inadequate to decide the appeal. Barr, supra. A report of VA examination dated in October 2015 shows that the Veteran reported headache symptoms of constant head pain, pulsating or throbbing head pain, and pain on both sides of the head. The Veteran also reported non-headache symptoms of nausea, sensitivity to light, sensitivity to sound, and changes in vision. The examiner noted prostrating attacks of headache pain, once every month. A report of VA examination dated in March 2016 shows that the Veteran reported headache symptoms of constant head pain, pulsating or throbbing head pain, pain localized to one side of the head, and pain that worsens with physical activity. The Veteran also reported non-headache symptoms of nausea, sensitivity to light, and sensitivity to sound. The examiner noted no prostrating attacks of headache pain. A report of VA examination dated in April 2018 shows that the Veteran reported headache symptoms of pulsating or throbbing head pain, and pain on both sides of the head, with non-headache symptoms of nausea, sensitivity to light, and sensitivity to sound. The examiner noted no prostrating attacks of headache pain. The Board finds that the March 2016 and April 2018 examinations are inadequate for adjudication as the examination reports do not contain sufficient analysis for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25 (2007) (a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record). Here, the March 2016 and April 2018 examiners opined that the Veteran’s migraines cause no prostrating attacks. However, the examiners provided no analysis for how they determined that the Veteran’s reports of migraines with throbbing pain, nausea, and light and sound sensitivity do not indicate prostrating attacks. Additionally, the examiners provided no analysis for how they determined that the prostrating attacks noted by the October 2015 examiner are no longer indicated. Further, the Board finds that the April 2018 examination is inadequate for adjudication as the examination report does not contain sufficient detail. See 38 C.F.R. § 4.2 (an examination report must be returned as inadequate when it does not contain sufficient detail). Here, the April 2018 examination report provides no indication that evidence showing that the Veteran’s migraines restrict his activity was considered by the examiner. Specifically, a statement from the Veteran’s spouse, submitted in August 2016, shows that she reported that the Veteran’s migraines “limit him from doing anything around the house because he cannot tolerate noise or even loud talking.” See Affidavit (August 2016). Additionally, a private treatment record from September 2017 shows that the treating clinician noted that the Veteran’s migraines restricted activity. See Medical Treatment Record - Non-Government Facility (August 2019). As the examination report provides no indication that relevant evidence was considered, it is lacking in detail. Moreover, no analysis was provided regarding why that evidence does not indicate prostrating attacks. See Stefl, supra. Accordingly, remand is required to ensure that VA has met its duty to assist. 38 C.F.R. § 3.159(c)(4). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for non-VA medical providers seen for the claimed disorders to include Rehab Service and McLeod Regional Medical Center Imaging. Make two requests for the all identified authorized records, unless it is clear after the first request that a second request would be futile. 2. Provide the Veteran, and his representative, a rating decision addressing whether there was clear and unmistakable error in the May 2017 rating decision that granted service connection for PTSD with depression and alcohol abuse (claimed a depression) to warrant limiting the scope of the grant to depression as secondary to neck disability. Conduct any development deemed necessary. 3. Schedule the Veteran for a VA psychiatric disorder examination by an appropriate clinician to address whether, as of May 1, 2014, the Veteran has had any acquired psychiatric disability, other than depression, that is at least as likely as not (a) had its onset during a period of active miliary service, or (b) is otherwise related to in-service injury or disease, to include the in-service complaints and assessments of depression and anxiety. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his all service-connected psychiatric disorders. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability or disabilities under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. 5. Schedule the Veteran for a peripheral nerve examination by an appropriate clinician to determine the severity of his service-connected radiculopathy of the right and left upper extremities. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria, to include information addressing his motor function, trophic changes, and sensory disturbance. 6. Schedule the Veteran for an examination of the current severity of his migraines. The examiner must be provided with a copy of the remand portion of this decision. The examiner is requested to opine on whether the Veteran’s reports of migraines with throbbing pain, nausea, and light and sound sensitivity indicate prostrating attacks. The examiner is also requested to review and discuss the relevance, if any, of the medical evidence showing activity restriction due to migraines cited herein, and opine on whether such indicates prostrating attacks. Further, if the examiner opines that the Veteran has no prostrating attacks, the examiner is requested to provide an analysis for how they determined that the prostrating attacks noted by the October 2015 examiner are no longer indicated. 7. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on next page) 8. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Thaddaeus J. Cox, Associate Counsel 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.