Citation Nr: 21074660 Decision Date: 12/16/21 Archive Date: 12/15/21 DOCKET NO. 18-06 705 DATE: December 16, 2021 ORDER Entitlement to an initial 70 percent rating for major depressive disorder prior to June 16, 2020 is granted. Entitlement to a rating in excess of 70 percent for major depressive disorder from June 16, 2020 is denied. Entitlement to service connection for a low back disability is denied. Entitlement to a total disability rating based on individual unemployability as due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to service connection for migraine headaches is remanded. FINDINGS OF FACT 1. For the entire period of the appeal, the date of the Veteran's initial claim seeking entitlement to the benefit, her major depressive disorder was shown to be productive of a disability picture that equated to occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; intermittent visual and auditory hallucinations; difficulty in adapting to stressful circumstances, sleep disturbances; disturbances of motivation and mood; and difficulty in establishing and maintaining effective relationships. 2. The competent evidence does not demonstrate that any diagnosed low back disability is attributable to the Veteran's active service or any incident of service. 3. The Veteran's service-connected disabilities together preclude her from obtaining or maintaining a substantially gainful occupation. CONCLUSIONS OF LAW 1. Prior to June 16, 2020, the criteria for an initial disability rating of 70 percent, but no more, for major depressive disorder have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.14, 4.40, 4.59, 4.130, Diagnostic Code 9411. 2. For the period beginning June 16, 2020, the criteria for a rating in excess of 70 percent for major depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.14, 4.40, 4.59, 4.130, Diagnostic Code 9411. 3. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for entitlement to TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1987 to December 1987, from February 1991 to April 1991, and from March 1994 to June 1994. These matters were last before the Board in June 2019, whereupon they were remanded for further development of the record. Ultimately, in an August 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted a 70 percent rating for major depressive disorder effective June 16, 2020. The AOJ subsequently issued a November 2020 supplemental statement of the case denying the service connection claims as well as entitlement to TDIU, and further denying a rating in excess of 50 percent for major depressive disorder prior to June 16, 2020 and a rating in excess of 70 percent thereafter. The claims have thus been returned to the Board for its adjudication. Entitlement to an Increased Rating for Major Depressive Disorder The Veteran is service-connected for major depressive disorder, initially rated as 50 percent disabling prior to June 16, 2020, and as 70 percent disabling thereafter. She seeks ratings in excess of those assigned for the entirety of the appeal period. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. 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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment due to gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126. Ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. When determining the appropriate disability evaluation to assign for psychiatric disabilities, however, the Board's "primary consideration" is the Veteran's symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013.) The Veteran has submitted a private psychiatric disability benefits questionnaire dated in November 2014 from a Dr. H.H.G., who indicated that she had reviewed the claims file. After she confirmed a diagnosis of major depressive disorder, Dr. H.H.G. found that the Veteran exhibited the following symptoms: depression, anxiety, suspiciousness, panic attacks more than once a week, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, persistent delusions and hallucinations, persistent danger of hurting self or others, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. In summation, she found that the PTSD contributed to occupational and social impairment with deficiencies in most areas, such as work, school family relations, judgment, thinking and/or mood. In a corresponding evaluation report also dated in November 2014, Dr. H.H.G. again noted that the Veteran experienced passive suicidal ideation as well as auditory and visual hallucinations that had been occurring for the entirety of the appeal period. According to the Veteran, she experienced severe depression and chronic sleep impairment resulting in a significant impairment in her quality of life. Dr. H.H.G. further detailed all of the symptomatology outlined in the disability benefits questionnaire. It was Dr. H.H.G.'s impression that the Veteran's major depressive disorder together with her right ankle disability precluded her from securing and maintaining substantially gainful employment. In support thereof, she highlighted the medical evidence of record demonstrating that the Veteran exhibited significant impairment in occupational functioning, including difficulty adapting to stressful situations, inability to concentrate, neglect of personal appearance/hygiene, mild memory loss, and lack of motivation. In addition, she related that the Veteran reported that she last worked in 2012 but quit that position after a suicide attempt. As Dr. H.H.G. in both the November 2014 disability benefits questionnaire and corresponding evaluation report thoroughly reviewed the claims file and referred to the Veteran's medical history as well as medical literature, the Board finds her determinations as to the severity of the Veteran's major depressive disorder and its impact on her employability to be highly probative. Sklar, supra. In addition to Dr. H.H.G.'s November 2014 report, the record contains numerous VA and private medical records reflecting that the Veteran has received extensive psychiatric treatment during the appeal period, to include admissions for suicidal ideation in November 2012, November 2015, and March 2016 for suicidal ideation. A January 2013 outpatient note from Wellstar Douglas Hospital also reflects that the Veteran complained of experiencing suicidal ideation and insomnia after running out of her anti-depressive medication. The Board acknowledges that the Veteran underwent VA psychiatric examinations in February 2013 and in June 2020, during which she denied experiencing all of the symptoms endorsed by Dr. H.H.G. in her November 2014 evaluation. With that being said, the Veteran still reported experiencing suicidal ideation on the February 2013 examination, which is borne out by her subsequent history of multiple admissions for the same during the appeal period. The Board also notes that on both VA examinations the Veteran exhibited symptoms of chronic sleep impairment, weekly panic attacks, disturbances of motivation and mood, neglect of personal appearance and hygiene, and difficulty in establishing and maintaining effective work and social relationships, all of which negatively impacted her social and occupational functioning. Despite this, both VA examiners determined that the major depressive disorder contributed only to occupational and social impairment with reduced reliability and productivity. It was on this basis that the AOJ assigned the initial 50 percent rating for major depressive disorder; conversely, however, the AOJ also assigned a 70 percent rating for the condition effective the date of the more contemporary VA examination despite the June 2020 examiner finding that the major depressive disorder contributed to the same degree of occupational and social impairment. The Board also finds that the February 2013 and June 2020 VA examinations are highly probative as they are based on a thorough review of the claims file and consideration of the Veteran's medical history. Sklar, supra. Ultimately, the Board finds that the evidence is at least in equipoise as to the question of whether the Veteran's major depressive disorder symptomatology has been commensurate with the 70 percent rating criteria for the entirety of the appeal period. Although the February 2013 VA examiner found that the symptoms of the condition contributed to no more than moderate impairment in social and occupational functioning, the Board has highlighted above those symptoms inherent in the 70 percent rating that were apparently not fully considered by the AOJ examiners, to include suicidal ideation, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective relationships, and significant sleep impairment. Taken together with those symptoms already encompassed in the 50 percent rating, these symptoms resulted in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran is entitled to an initial evaluation of 70 percent. However, the Veteran's symptomatology does not meet the criteria for a 100 percent rating at any time during the appeal period. While the evidence does show that the Veteran has reported experiencing hallucinations, there is no evidence that she has ever acted on those hallucinations or that they have resulted in spatial or temporal disorientation. Furthermore, although she was noted to exhibit neglect for her personal hygiene and appearance on both VA examinations, she did not exhibit grossly inappropriate behavior, which is another component of a 100 percent evaluation. Moreover, while the Veteran has reported experiencing memory issues during the VA examinations as well as during the November 2014 evaluation with Dr. H.H.G., there is no suggestion that she experienced memory loss for her own name or names of close relatives during the appeal period. Most significantly, there is no indication that she experienced total occupational and social impairment as due to her service-connected major depressive disorder. Accordingly, a 100 percent evaluation is not warranted. Entitlement to Service Connection for a Low Back Disability The Veteran seeks service connection for a low back disability as directly attributable to the physical toll of her duties in service. Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a low back disability that began during service or are at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has been diagnosed with degenerative arthritis of the spine, the preponderance of the evidence is against a finding that a low back disability began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.310. A review of available service medical records does not show that the Veteran ever complained of low back symptomatology, nor was she ever diagnosed with or treated for a low back disability. Specifically, no low back symptomatology was noted on a March 1991 periodic examination or the corresponding March 1991 Report of Medical History. Post-service, VA medical records reflect that the Veteran began seeking treatment for back pain in June 2012. A radiographic examination at that time revealed multi-level degenerative disc disease and facet joint disease in the lumbar spine. Thereafter, a July 2012 outpatient note shows that the Veteran reported that her back pain began in December 2011 following a motor vehicle accident. Subsequent records do show that the Veteran has continued to receive treatment through VA for low back pain. However, at no point has any treating VA medical professional ever associated the low back pain with the Veteran's service. Submitted private medical records show treatment for low back pain generally. However, no treating medical provider has found any association between this pain and the Veteran's service. During a February 2013 general medical examination, it was noted that the Veteran had low back pain characterized as multilevel degenerative disc disease of the lumbar spine. The examiner noted that the pain began in December 2011 following a motor vehicle accident, but also acknowledged the Veteran's self-report that she had been experiencing back pain since service. The examiner did not offer an opinion as to the likely etiology of the low back pain, as the examination was being conducted for pension purposes, and thus the issue of possible nexus to service was not before VA at that time. The nature and likely etiology of the claimed low back disability was evaluated in an August 2020 VA spine examination, during which the Veteran reported that she began experiencing low back pain following a total right knee replacement in service. After an in-person examination, the Veteran was diagnosed with degenerative arthritis of the spine. The examiner then opined that it was less likely than not that the Veteran has a low back disability that was incurred in or is otherwise attributable to service, on the grounds that there was no documentation of treatment for low back symptomatology while in service and for more than a year following the Veteran's discharge. The Board finds the August 2020 examination and opinion to be highly probative as the VA examiner reviewed the claims file, carried out an in-person examination, and referred to the Veteran's medical history in support of their conclusions. Sklar v. Brown, 5 Vet. App. 140 (1993). Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that the Veteran has a low back disability that is attributable to service. To begin, the service treatment records do not document any complaints or treatment related to a low back disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Moreover, as stated the Board finds highly probative the opinion of the August 2020 VA examiner, who confirmed the lack of in-service treatment for low back symptomatology and further highlighted the lack of subsequent medical care for low back symptomatology for several years following service. The Board acknowledges that during the February 2013 and August 2020 examinations, the Veteran contended that her low back pain began in service following right knee surgery. However, while the Veteran is certainly competent to detail her own personal account of the progression of her low back pain, she does not have the medical training or credentials to offer an opinion as to a diagnosis or its etiology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Furthermore, her statement during the August 2020 examination is directly contradicted by her report about the incidence of back pain when she first sought treatment for the condition in 2012. Under these circumstances, without any positive objective evidence tending to support the Veteran's assertion that her low back disability began in service, and in light of the highly probative opinion of the August 2020 examiner, the Board finds that the preponderance of the evidence is against a determination that the low back disability began in service. Accordingly, service connection on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. The Veteran may still be entitled to service connection if all of the evidence establishes that the low back disability was incurred in service. 38 C.F.R. § 3.303(d). Here, however, there is no objective evidence of incurrence in service, and again there is a gap of several years between discharge and when the Veteran first sought treatment for symptoms of low back pain in 2012. She has not presented, and the claims file does not otherwise contain, any medical evidence supporting a causal link between a low back disability and her service. Furthermore, the Veteran's assertion that she has a low back disability that is attributable to service is outweighed by the opinion of the August 2020 VA examiner. Without any competent medical evidence in support of the claim to outweigh the probative negative etiology opinion of record, the Board finds that the preponderance of the evidence is against a determination that a medical nexus exists between the Veteran's degenerative arthritis of the spine and an in-service injury, event, or disease. Service connection for a low back disability under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim of entitlement to service connection in total must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the preponderance of the evidence is against the claim of service connection for a low back disability, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Entitlement to TDIU Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the claimant's service-connected disabilities is less than 100 percent, and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities sufficient to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to her age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. As stated by the Board in its prior June 2019 remand, the issue of entitlement to TDIU was raised as part and parcel to the rating claim for major depressive disorder. Specifically, the Board highlighted that the Veteran has asserted that her service-connected disabilities, specifically her major depressive disorder, have precluded her from securing and following substantially gainful employment. In acknowledgement of the guidance outlined in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board will review the propriety of the TDIU claim for the entire appeal period. To that end, the Board notes that with the newly assigned rating for major depressive disorder, the Veteran has been in receipt of a 70 percent rating throughout the appeal period. Thereafter, she was also assigned a 10 percent rating for a right ankle condition. This additional rating does not change the cumulative rating. As such, the Veteran has met the schedular requirements for the grant of TDIU for the entirety of the appeal period. That being said, the Board highlights that an award of TDIU is still contingent on a finding that the Veteran's service-connected disabilities precluded her from securing and following substantially gainful employment. After a review of the record, and granting the Veteran the benefit of the doubt, the Board finds that the preponderance of the evidence supports a determination that the Veteran has been precluded from securing and following substantially gainful employment as a result of her service-connected disabilities. To begin, following the Board's June 2019 remand, the Veteran in July 2019 submitted her formal claim seeking entitlement to TDIU, wherein she contended that both of her service-connected disabilities precluded her from securing or following substantially gainful employment. She detailed that she last worked full-time in May 2012, which is when her disabilities first affected employment. She also specified that she worked from 2007 to May 2012 when she stopped working entirely; she attributed her reason for leaving work in May 2012 to her service-connected disabilities. As discussed previously, the claims file contains a copy of a November 2014 disability benefits questionnaire and corresponding evaluation from a Dr. H.H.G. Without reiterating the details of that evaluation in its entirety, the Board highlights that Dr. H.H.G. stated that the Veteran could not "sustain the stress from a competitive work environment and [could not] be expected to engage in gainful activity due to her major depressive disorder." See Evaluation of Dr. H.H.G., November 20, 2014. In support thereof, Dr. H.H.G. described the Veteran's multiple psychiatric symptoms and the deleterious impact they had while she did work and would continue to have if she attempted to work again. Dr. H.H.G. also noted that the Veteran specifically ceased working in May 2012 after she attempted suicide and was unable to return to work thereafter. The Board also highlights the findings of the two VA examiners who evaluated the nature and severity of the major depressive disorder during the appeal period, first in February 2013 and again in June 2020. While both examiners found that the condition would contribute to occupational and social impairment with reduced reliability and productivity, which equates to only a moderate degree of interference with occupational functioning, the February 2013 examiner specifically commented that the Veteran's medical problems prohibited her from working. Similarly, the June 2020 examiner commented that the major depressive disorder impeded the Veteran's concentration, attention and awareness and contributed to low energy and increased irritability, all of which would greatly impact the Veteran's occupational functioning. In addition to the impact of the major depressive disorder on the Veteran's occupational functioning, the Board notes that in a June 2013 VA ankle examination a VA examiner commented that the right ankle disability contributed to difficulty with prolonged standing, walking, or driving. After a review of the record, and without the necessity of detailing the extensive medical record in full, the Board finds that the available evidence is at least in equipoise as to the issue of whether the Veteran's service-connected disabilities precluded her from securing and following substantially gainful employment during the appellate period. Although the various VA examiners who have evaluated the severity of the Veteran's service-connected disabilities have not agreed as to the degree of impact those disabilities have had on her occupational functioning, there is large consensus that those disabilities together significantly impair her ability to function satisfactorily in a work setting. Both the VA examiners of record as well as Dr. H.H.G. found that the major depressive disorder would significantly interfere with the Veteran's ability to focus on her work and cooperate with other employees, while the VA examiner while evaluated the right ankle noted that the condition would impair the Veteran's ability to carry out some amount of physical work-related duties. Taken together, the Board finds that the Veteran's service-connected disabilities prevented her from securing and following substantially gainful employment for the entirety of the appeal period. As such, TDIU is granted for the entirety of the appeal period. The Board notes that as the Veteran is not in receipt of service-connected disabilities independent of those that form the basis of the TDIU grant and which are independently ratable at 60 percent, special monthly compensation at the (s) rate is not warranted. See Bradley v. Peake, 22 Vet. App. 280 (2008) (analyzing 38 U.S.C. § 1114 (s)). REASONS FOR REMAND Migraine Headaches The Board in June 2019 remanded the issue of entitlement to service connection for migraine headaches in order to secure a VA examination and opinion addressing the nature and likely etiology of the claimed migraine headache condition. Specifically, the Board requested that the chosen examiner opine as to the likelihood that the Veteran had a migraine headache condition that was caused and/or aggravated by a service-connected disability. In an March 2020 examination, a VA examiner confirmed that the Veteran had a diagnosed migraine headache condition and acknowledged her reports that she had been experiencing chronic headaches ever since service. After reviewing the claims file, the examiner opined that it was less likely than not that the Veteran had a migraine headache condition that was incurred in or otherwise attributable to service. In support thereof, the examiner detailed the lack of documentation of headache symptomatology in service, and further noted that the Veteran was not formally diagnosed with a headache condition until 2016, over 20 years after her discharge from service. As the March 2020 examiner did not opine as to a possible secondary nexus between the migraine headache condition and a service-connected disability, the AOJ secured an August 2020 addendum opinion from the March 2020 examiner to address secondary service connection. After confirming review of the claims file, the examiner first found that it was less likely than not that the headache condition was proximately caused or aggravated by the service-connected right ankle disability, on the grounds that the two conditions do "not share an etiological pathway, making it unlikely as a cause and effect relationship." See August 2020 Addendum/Clarification Disability Benefits Questionnaire. The August 2020 examiner then found that it was less likely than not that the migraine headache condition was proximately cause or aggravated by the service-connected major depressive disorder. In support thereof, the examiner acknowledged that there was a loose association with migraine headaches and depression and specified that medical literature suggests that headache can cause depression due to the chronicity of the headache and its impact on daily life activities. The examiner then discussed medical literature linking headaches with hypertension and obesity, and she highlighted that the Veteran had both of these risk factors for the development of headaches. The Board also notes that in a separate statement, the August 2020 examiner related that the any question as to causality between migraine headaches and the major depressive disorder should be provided by a mental health provider; she then highlighted that the VA examiner who evaluated the severity of the Veteran's major depressive disorder in June 2020 did not even mention her migraine headache condition. The Board cannot rely on the August 2020 addendum opinion as to the possible secondary nexus between the migraine headache condition and the Veteran's service-connected disabilities. As such, remand is necessary to secure new opinions that adequately address this query. Specifically, with regard to the potential relationship between the migraine headache condition and the service-connected right ankle disability, the August 2020 opinion is supported only by the conclusory statement that the two disabilities do not share an "etiological pathway", and there is no actual discussion of medical evidence or literature to support this statement. As for the potential relationship between the migraine headache condition and the service-connected major depressive disorder, the examiner did not offer any explanation as to why she presumably determined that the headache condition was more likely attributable to the Veteran's comorbid risks factors of hypertension and obesity as opposed to the conceded potential association between headaches and depression. Moreover, the examiner herself acknowledged that this opinion in particular should be provided by a mental health provider, which the August 2020 examiner is not. Accordingly, remand is necessary in order to secure an opinion that is responsive to the Board's prior June 2019 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: Provide the claims file to a qualified VA mental health provider (psychiatrist or psychologist) for the purpose of eliciting a further addendum opinion as to the likely etiology of migraine headache condition. The entire claims file, including this REMAND, must be made available to the chosen examiner, and that individual must indicate review of the claims file prior to setting forth any opinion. The chosen examiner must set forth an opinion as to whether it is it at least as likely as not (an approximate balance of positive and negative evidence) that the migraine headache condition had its onset during service or is otherwise related to active service. In addition, irrespective of the answer to the above, the examiner is also requested to provide an opinion as to whether it is at least as likely as not that the migraine headache condition was caused or aggravated by one or more service-connected disabilities (as listed in a January 2020 rating decision). The examiner must discuss the possibility that the migraine headache condition is attributable to each service-connected disability, to include whether the condition was aggravated by a service-connected disability (defined as any increase in disability). The examiner should specifically address the conceded association between headaches and depression highlighted by the August 2020 VA examiner. If the opinion is that a service-connected disability or combination of service-connected disabilities aggravated the migraine headache condition, the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. All provided opinions must be supported by a complete rationale that considers and discusses both the lay and medical evidence of record. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Collins, 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.