Citation Nr: 21071337 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-13 591 DATE: November 30, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for headaches, to include as secondary to service-connected disabilities, is remanded. INTRODUCTION The Veteran served on active duty from September 1988 to September 1991 and from February 2002 to July 2003, with additional service in the Reserves. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2021 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In June 2021, the Board remanded these claims for additional development. After the issuance of an August 2021 supplemental statement of the case, the appeal has been remitted to the Board for further appellate review. REASONS FOR REMAND In an October 2021 brief, the Veteran's representative correctly asserts that the Veteran's private and service treatment records indicate complaints of low back pain due to an injury. Specifically, an April 1996 note from a private doctor, M.R.A., M.D., states that he was treating the Veteran for a "back injury," and found that the Veteran should be excused from physical and endurance examinations. According to a June 1996 service treatment record, the Veteran complained of "occasional back pain." Also, a July 1996 service treatment report indicated that the Veteran was granted a medical waiver for low back pain secondary to an injury, which was established by a private provider note (presumably, Dr. A's April 1996 note). The Veteran served on active duty from September 1988 to September 1991 and from February 2002 to July 2003, with additional service in the Reserves. It is unclear from the evidence of record if the Veteran's back injury occurred during a period of service. Additionally, if the Veteran sustained a back injury in 1996, there remains a question as to whether it resulted in a disability which was then aggravated beyond its natural course during his period of active duty from February 2002 to July 2003. With respect to headaches, the Veteran's representative asserts a July 2021 supplemental opinion is conclusory and, thus, is inadequate. The Board agrees. Further, the examiner did not consider whether any medication prescribed to treat a service-connected disability caused or aggravated the Veteran's headaches. For the above-stated reasons, the Board finds that another remand is warranted for additional development. The matters are REMANDED for the following action: 1. Verify each period of the Veteran's military service, to include the periods of his Reserve service. Verify the status of each such period (i.e., active duty, active duty for training, or inactive duty for training). 2. Request that the Veteran submit or identify records associated with his back treatment administered by Dr. A., to include, but not limited to, those dated in 1996. 3. Then, obtain supplemental opinions from VA examiners who conducted the July 2021examinations regarding the Veteran's back disability and headaches. If either of the respective examiners is unavailable, qualified substitutes may be engaged. The Veteran's electronic claims file must be made available to the examiners and the examiners must specify in the report that it was contemporaneously reviewed. All pertinent symptomatology and findings must be reported. Back Disability The appropriate examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's back disability was incurred in or due to his active duty. This examiner is also requested to provide an opinion as to whether a back disability clearly and unmistakably pre-existed the Veteran's period of active duty from February 2002 to July 2003 and, if so, whether it was clearly and unmistakably not aggravated therein. In addressing these questions, the examiner must consider and discuss the Veteran's report of in-service events and the 1996 private and service treatment records, as well as any additional treatment records obtained from Dr. A. Headaches The appropriate examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's "acute intermittent tension type headaches" were incurred in or due to the Veteran's active duty. This examiner must also provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's "acute intermittent tension type headaches" are caused or aggravated by a service-connected disability. In so doing, the examiner must specifically consider and discuss whether any medication prescribed to treat the Veteran's service-connected disabilities caused or aggravated his headaches. All rendered opinions must be accompanied by a thorough rationale. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sean G. Pflugner, 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.