Citation Nr: 21062064 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 18-19 257 DATE: October 6, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for acquired psychiatric condition, to include depression, is remanded. Entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from February 1978 to September 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In the Veteran's March 2018 appeal, he requested a Board hearing and was afforded a hearing in January 2021. 1. Entitlement to service connection for bilateral hearing loss is remanded. 2. Entitlement to service connection for acquired psychiatric condition, to include depression, is remanded. 3. Entitlement to service connection for migraine headaches is remanded. Although the Board is aware this case has been on appeal since March 2018 and additional delay is regrettable, a remand is necessary to allow the Board to make a fully informed decision regarding the Veteran's claim. The Veteran's claim was originally denied in part for lack of a current disability of hearing loss. During the Veteran's January 2021 hearing, he testified his bilateral hearing loss had increased in severity since he was last examined by VA in August 2017. Therefore, the Board finds the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his bilateral hearing loss. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). In addition, the Veteran testified that his depression and headaches were secondary to his chronic pain and the stress from his medical conditions. The Veteran also stated that his depression was secondary to the medication he was taking for his chronic pain and that his headaches were due to noise exposure during service. See December 2017 NOD and March 2018 Form 9 Appeal. The December 2015 VA examinations do not discuss secondary causation for the Veteran's depression or migraine headaches. There is an indication that the Veteran's disabilities may be related to a service-connected disability, but there is insufficient competent evidence in the file to decide the claim. Therefore, a VA addendum medical opinion is warranted to determine the etiology of the Veteran's migraine headaches and acquired psychiatric condition, including depression. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Accordingly, the Board finds a remand is necessary for an addendum medical opinion to determine the nature, etiology, symptoms, and severity of the Veteran's migraine headaches and acquired psychiatric condition. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a TDIU claim form (VA Form 21-8940) and, after an opportunity to respond, adjudicate entitlement to a TDIU in the first instance. 2. Schedule the Veteran for an examination with an appropriate medical professional to determine the current severity, nature and etiology of the Veteran's bilateral hearing loss. The claims file must be made available for review, and the examination report should reflect that such review occurred. After reviewing the claims file and completing a physical examination of the Veteran, the examiner must: a. Determine whether a hearing loss disability exists. b. If there is a hearing loss disability, provide an opinion for any hearing loss disability found on examination, as to whether it is at least as likely as not (50 percent or greater probability) that the disorder 1) began during active-duty service; or, 2) is related to any incident/event of the Veteran's active-duty service. In offering this opinion, the examiner must discuss the Veteran's statements regarding his noise exposure while working on the flight deck of the U.S.S. America and document the Veteran's contentions in the examination report. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. 3. Obtain an addendum medical opinion from an appropriate medical professional to determine the nature, etiology, and severity of the Veteran's acquired psychiatric condition, including depression. The claims file must be made available for review, and the examination report should reflect that such review occurred. After reviewing the claims file the examiner must: a. Identify the Veteran's current psychiatric conditions. b. Provide an opinion for any diagnosed acquired psychiatric condition found on examination as to whether it is at least as likely as not (50 percent or greater probability) that the condition 1) began during active-duty service; or, 2) is related to any incident/event of the Veteran's active-duty service. c. Provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the Veteran's psychiatric disability was (A) caused or (B) aggravated beyond its normal progression by 1) the Veteran's other service-connected conditions, 2) the Veteran's reported chronic pain, or 3) the Veteran's medication used to treat his chronic pain. Aggravation means an increase in disability any additional impairment of earning capacity - of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. 4. Obtain an addendum medical opinion from an appropriate medical professional to determine the nature, etiology, and severity of the Veteran's migraine headaches. The claims file must be made available for review, and the examination report should reflect that such review occurred. After reviewing the claims file the examiner must: a. Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that his migraine headaches 1) began during active-duty service; or, 2) are related to any incident/event of the Veteran's active-duty service. b. Provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the Veteran's migraine headaches were (A) caused or (B) aggravated beyond its normal progression by 1) the Veteran's other service-connected conditions, 2) the Veteran's reported chronic pain, or 3) the Veteran's medication used to treat his chronic pain. Aggravation means an increase in disability any additional impairment of earning capacity - of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (Continued on the next page) A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Aubee, 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.