Citation Nr: 21003382 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 16-49 788 DATE: January 21, 2021 REMANDED Service connection for headaches is remanded. Service connection for a head scar is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1963 to June 1965. This case is before the Board of Veterans’ Appeals (Board) on appeal from September 2014 and May 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decisions. In the September 2014 decision, the RO denied service connection for headaches. In the May 2015 rating decision, the RO continued the denial of service connection for headaches and denied service connection for a head scar. In June 2015, VA received the Veteran’s Notice of Disagreement (NOD). As the June 2015 NOD was timely as to the original denial of service connection for headaches in the September 2014 rating decision, as noted in the prior March 2020 Board decision, there was no final denial of the claim for service connection for headaches and, therefore, the claim remained on appeal. In September 2016, the RO issued a Statement of the Case (SOC), and the Veteran’s VA Form 9, substantive appeal was received in October 2016. In December 2019, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that testimony is of record. In March 2020 the Board remanded the case for further development and adjudicative action. 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for a head scar. As noted in the prior March 2020 Board remand, the Veteran testified to losing consciousness and receiving stitches after hitting his head on a bulkhead on the USS Enterprise. Following the injury, he reported developing pain and tenderness in the area of a scar from the head injury and headaches lasting up to several days every two or three weeks. See December 2020 Board hearing transcript. Pursuant to the March 2020 Board remand, the Veteran received a new VA examination for his headaches and head scar in April 2020. During the examination, he indicated that the head injury occurred in 1965. In the examination report, the VA examiner concluded, “after thorough inspection,” that the Veteran did not have a head scar. Furthermore, the VA examiner found that the Veteran’s headaches were less likely than not related to service, in light of a lack of medical evidence of in-service reports of or treatment for headaches or a head injury. In an October 2020 statement, the Veteran reported that the VA examiner never got within five feet during the examination, apparently due to social distancing guidelines related to the Covid-19 pandemic. Furthermore, he indicated that the “appointment itself lasted less than a minute.” October 2020 Veteran statement. The examination report itself provides no indication that the examiner physically examined the Veteran. Thereafter, the Veteran shaved his head, “so that the scar was clearly visible,” and, in October 2020, visited his local VA medical center, where a VA primary care physician “acknowledged the presence of the scar.” Id. These VA treatment records have not been associated with the claims file. The March 2020 Board remand also instructed the RO to associate with the claims file any outstanding STRs and deck logs for the USS Enterprise. Thus far, deck logs from November and December 1963, April and September 1964, and February and April 1965 have been associated with the claims file. However, deck logs for numerous other periods during the Veteran’s active service, including for January and March 1965, have not been uploaded; to date, the RO has not made a formal finding that these records are unavailable. Finally, the March 2020 Board remand instructed the RO to obtain December 2019 private treatment records showing the results of a CT scan. There is no indication that the RO attempted to locate these records. In light of the above, given that the Veteran did not receive a thorough VA examination of his head scar, another VA examination is warranted for the Veteran’s head scar. Given that the claim for service connection for headaches is inextricably intertwined with the claim for service connection for a head scar and is contingent on records currently missing from the claims file, the examiner should provide VA opinions for both claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The RO should ensure that complete VA treatment records, particularly those from October 2020, deck logs for the USS enterprise, including logs from January and March 1965, and private treatment records, particularly the December 2019 CT scan report, are associated with the claims file or otherwise explain why these records are unavailable. The matters are REMANDED for the following action: 1. With appropriate authorization from the Veteran, obtain and associate with the claims file all of the Veteran’s outstanding private treatment records relevant to the pending claims on appeal, including the results of a recent CT scan, most likely from November or December 2019; furthermore, obtain any outstanding VA treatment records, including records from October 2020. All efforts to locate these records should be fully documented in the claims file. 2. Obtain all outstanding deck logs from the USS Enterprise related to the Veteran’s service, including deck logs between November 1963 and April 1965 that have not already been obtained. As noted above, deck logs from November and December 1963, April and September 1964, and February and April 1964 have already been obtained but deck logs for other periods, including for January and March 1965 have not been obtained. 3. Thereafter, schedule the Veteran for a VA examination by an appropriate clinician to determine the nature and etiology of the headaches and head scar. The claims folder, including a copy of this Remand, should be made available to and reviewed by the examiner in connection with the examination. A complete rationale for all opinions must be provided. The examiner should provide a thorough physical examination of the Veteran’s scalp. (Continued on the next page)   Based on the Veteran’s statements and the evidence of record, to include VA and private treatment records and deck logs (including any records newly associated with the claims file pursuant to this remand), the VA examiner must opine whether the headaches and head scar are at least as likely as not related to an injury, event, or disease during active service, including the claimed head injury occurring in approximately 1965. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Small, 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.