Citation Nr: 21005742 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 13-03 691A DATE: February 2, 2021 ORDER Entitlement to a rating in excess of 30 percent for residuals of bilateral bunionectomy, to include degenerative arthritis, is denied. REMANDED Entitlement to a rating in excess of 30 percent for vascular and tension headaches, prior to September 21, 2016, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU), prior to May 12, 2016, is remanded. FINDING OF FACT The Veteran’s residuals of bilateral bunionectomy, to include degenerative arthritis, is manifested by no more than severe symptoms without actual loss of use of either foot. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for residuals of bilateral bunionectomy, to include degenerative arthritis, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC)s 5003, 5284. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from March 1989 to March 1993. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Regarding procedural history, the September 2012 rating decision granted a disability rating of 20 percent for foot injuries based on moderately severe symptoms of the Veteran’s bilateral bunionectomy residuals. The Veteran timely filed a notice of disagreement (NOD) regarding the evaluation of the service connected residuals of bilateral bunionectomy. See September 2012 NOD. In a December 2012 rating decision, the RO increased the Veteran’s disability rating of 20 percent to 30 percent, effective July 9, 2012, the date the Veteran filed for an increased rating. See July 2012 VA 21-0820, Report of General Information. A December 2012 statement of the case (SOC) continued the 30 percent rating for the Veteran’s residuals of bilateral bunionectomy. In February 2013, the Veteran filed a timely substantive appeal requesting 50 percent for her residuals. See February 2013 VA Form 9. In May 2016, VA received a second request for an increased rating of the Veteran’s service-connected residuals of bilateral bunionectomy. See May 2016 VA 21-526EZ, Fully Developed Claim. In October 2017, a supplemental statement of the case (SSOC) denied an increased rating in excess of 30 percent for service-connected residuals of bilateral bunionectomy. In a February 2018 Board decision, the Board denied increase ratings in excess of 30 percent for residuals of bilateral bunionectomy, in excess of 30 percent for vascular and tension headaches prior to September 21, 2016, and in excess of 50 percent for vascular and tension headaches from September 21, 2016; however the Board granted entitlement to TDIU. The Veteran timely appealed the February 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In November 2018, the Veteran filed a VA 21-526EZ requesting service-connection for bilateral foot arthritis secondary to bunionectomy, along with additional claims. Thereafter, in a December 2018 Court Order, pursuant to a November 2018 Joint Motion for Partial Remand (JMPR) submitted by the parties, the Court vacated and remanded the portions of the February 2018 Board decision dealing with the evaluation in excess of 30 percent for residuals of bilateral bunionectomy to include a discussion of an August 2012 radiology report for a possible separate rating according to 38 C.F.R. § 4.71a, DC 5003, and the evaluation in excess of 30 percent for vascular and tension headaches prior to September 21, 2016 for additional development. The Veteran did not appeal the Board’s decision regarding entitlement to an evaluation in excess of 50 percent for vascular and tension headaches from September 21, 2016, and the grant of entitlement to TDIU. In January 2019, the Veteran committed to a VA foot conditions examination and a February 2019 rating decision denied service connection for bilateral foot arthritis. The Veteran provided additional medical records in March 2019, and an April 2019 VA foot conditions exam occurred. Thus, the February 2019 rating decision did not become final based on the evidence then of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.1103; Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). Additionally, the Veteran filed a supplemental claim with the submission of additional medical records regarding service connection for bilateral foot arthritis. See April 2019 VA Form 20-0995, Decision Review Request: Supplemental Claim; October 2018 to March 2019 D.C. Treatment Records. In May 2019 and August 2019, VA foot conditions examinations took place, and an August 2019 rating decision denied service connection for bilateral foot arthritis as evidence submitted was not new and relevant. The Veteran did not file a NOD; however, additional evidence pertinent to the issue was associated with the claims folder within one year of the August 2019 rating decision. See December 2019 Private Right Foot Radiology Impression; January 2020 VA Foot Conditions Disability Benefits Questionnaire (DBQ). Thus, the August 2019 rating decision did not become final based on the evidence then of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.1103; Bond, supra; Buie, supra. Additionally, in a May 2019 Board decision, the Board denied a disability rating in excess of 30 percent for vascular and tension headaches, prior to September 21, 2016, and z disability rating in excess of 50 percent for vascular and tension headaches, from September 21, 2016; however, the Board remanded the issues of a disability rating in excess of 30 percent for residuals of bilateral bunionectomy and a TDIU prior to May 12, 2016. In May 2020, pursuant to a May 2020 JMPR, the Court vacated and remanded the issue of entitlement to a disability rating in excess of 30 percent for vascular and tension headaches prior to September 21, 2016. Additionally, the Court noted that the Board remanded the issues of an increased rating in excess of 30 percent for residuals of bilateral bunionectomy and TDIU prior to May 12, 2016, thus, those issues were not before the Court. Further, the Court informed the claim for entitlement to a disability rating in excess of 50 percent for vascular and tension headaches, beginning September 21, 2016, was dismissed prior to the December 2018 JMPR. See May 2020 JMPR. In an August 2020 SSOC, the RO continued the current 30 percent disability rating for the Veteran’s service-connected residuals of bilateral bunionectomy and denied a TDIU prior to May 12, 2016. Increased Rating Law Under DC 5003, degenerative or traumatic arthritis established by x-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. However, in the absence of limitation of motion, the disability is to be rated as 10 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups; and as 20 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Disability ratings under DC 5003 is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added. Multiple involvements of the interphalangeal, metacarpal, and carpal joints of the upper extremities are considered groups of minor joints. 38 C.F.R. § 4.45. Diagnostic Code 5284 provides rating criteria for other foot injuries. A moderate foot injury warrants a 10 percent disability evaluation. A moderately severe foot injury warrants a 20 percent disability evaluation and a severe foot injury is assigned a 30 percent disability evaluation. A 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, DC 5284. VA General Counsel has determined that DC 5284 is a general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations, for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect the range of motion. Thus, General Counsel concluded that, depending on the nature of the foot injury, DC 5284 may involve limitation of motion. VAOPGCPREC 9-98. The words “moderate,” “moderately severe,” and “severe” as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. With respect to degenerative arthritis, the Board finds that DC 5284 is for application because this disability resulted from an actual foot injury and is not specifically contemplated under another diagnostic code. Yancy v. McDonald, 27 Vet. App. 484, 492-93 (2016) (holding that application of DC 5284 is limited to disabilities resulting from actual injuries to the foot, but that unlisted conditions may be rated by analogy to injury of the foot under DC 5284); 38 C.F.R. § 4.20 (providing that unlisted conditions may be rated by analogy under a closely related disease or injury). “The plain meaning of the word “injury” limits the application of DC 5284 to disabilities resulting from actual injuries to the foot, as opposed to disabilities caused by, for example, degenerative conditions.” Yancy, 27 Vet. App. at 491. Rating by analogy under DC 5284 is therefore appropriate concerning the service-connected degenerative arthritis. 1. Entitlement to a rating in excess of 30 percent for residuals of bilateral bunionectomy, to include degenerative arthritis, is denied. The Veteran is currently in receipt of a 30 percent rating from July 9, 2012, for her service-connected bilateral foot disability. The current appeal period before the Board is from July 9, 2012, the date of her increased rating claim, plus the one year “look back” period. Gaston v. Shinseki, 605 F.3d 979, 982 Fed. Cir. (2010). In an August 2012 statement, the Veteran asserted that her bunionectomy residuals have worsened. She stated that she cannot wear shoes for extended periods, as her feet swell, and her toes numb, tingle, and burn. The Veteran underwent a VA examination in July 2014, and the examination report indicated a 1992 diagnosis of hallux valgus and an April 2014 diagnosis of Morton’s neuroma. The examination report further indicated a bunion surgery in 1992. The Veteran’s complaints of pain, tingling, and burning in both feet are documented in the report. During the 2014 exam, the feet were tender to pressure, and reported functional loss in the form of limited ability to stand or walk due to increased bilateral foot pain was noted. Additionally, the 2014 examination report specifies pain on weight-bearing with both feet, with imaging studies revealing no arthritis, without discussing the August 2012 x-rays. The examiner opined that the Veteran’s current symptoms were not attributable to residuals of bunionectomy, but rather to Morton’s neuroma. Thus, the July 2014 medical opinion is considered inadequate for arthritis purposes only. Stefl v. Nicholson, 21 Vet. App. 120 (2007). The Veteran underwent another VA examination in August 2016, during which the examination report noted a diagnosis of status post-bunionectomy and left scar tissue removal with residual pain. The 2016 examination report indicated that the Veteran reported having surgery to remove scar tissue in 2014, but since that time the condition worsened. Further, the 2016 examination report indicated that the Veteran described constant sharp pain in the feet and functional loss due to her inability to wear closed-toe shoes, or stand or ambulate for extended periods of time. The 2016 examination report noted mild or moderate symptoms associated with hallux valgus, for which the Veteran had surgery in 1992 and 2014. Additionally, the 2016 examination report specifies that the residual symptoms from the Veteran’s surgeries were found to be pain, swelling, and limited ability to bear weight. The 2016 examination report revealed bilateral pain on movement, pain on weight-bearing, swelling, disturbance of locomotion, and interference with standing, as well as pain on non-weight-bearing in the left foot. Moreover, repetitive use testing revealed increased pain and swelling and decreased ability to bear weight in both feet. See August 2016 VA Foot Conditions Examination Disability Benefits Questionnaire (DBQ). The 2016 examiner indicated that the Veteran’s condition was not so severe that no effective function remained other than what would be equally served with amputation with prosthesis. Id. However, the 2016 examination report failed to discuss the August 2012 x-rays and indicated no imaging studies were performed. As such, the examination report is inadequate for arthritis determinations as well. Stefl, supra. The Veteran underwent a third VA foot conditions examination in January 2019. The January 2019 examination report indicated that the Veteran described severe pain and numbness in the feet at a 7 out of 10 on a scale of 1 to 10, and flare-up as numbness, tingling, sharp shooting pain, and dull constant ache. The January 2019 examination report described functional loss in that she is no longer as active as she was before, and cannot stand, walk, or wear shoes for extended periods of time. The January 2019 examination report noted that the Veteran’s left Morton’s neuroma, bilateral metatarsalgia, and hallux valgus had mild or moderate symptoms from the Veteran’s 1992 and 2014 surgeries. The January 2019 examination report specified that a residual symptom from the Veteran’s 2014 neuroma surgery was left foot numbness, and the examination, itself, revealed bilateral pain on movement, less movement than normal, weakened movement, and pain on weight-bearing. Additionally, the January 2019 examination report showed that repetitive use testing revealed no increased pain or functional loss due to flare ups in both feet. The January 2019 examiner found that the Veteran’s condition was not so severe that no effective function remained other than what would be equally served with amputation with prosthesis. See January 2019 VA Foot Conditions Examination DBQ. However, the January 2019 examiner indicated no imaging studies were available, thus no arthritis. Id. Thus, the January 2019 medical opinion is considered inadequate for arthritis reasons only. Stefl, supra. In May 2019, a fourth VA foot conditions examination took place. The May 2019 examination report indicated that the Veteran reported sharp pain with the same for flare-ups, and functional loss due to her difficulties in walking for long periods of time. The May 2019 examination report discussed the Veteran’s left Morton’s neuroma in the “other foot injuries section”, indicating left foot moderate severity, with no compromise of weight-bearing or requirement for arch supports, inserts, or shoe modification. Additionally, the May 2019 examination report specified that the residual symptoms from the Veteran’s 2014 neuroma removal and 2019 correction of same were pain and stiffness. Further, the May 2019 examination report specified that upon examination increased left foot pain was noted on movement and with weight-bearing, while repetitive use testing and flare-up testing indicated left foot increased pain with prolonged walking. Further, the May 2019 examination report specified left foot pain on movement and weight-bearing. The May 2019 examiner found the Veteran’s condition was not so severe that no effective function remained other than what would be equally served with amputation with prosthesis. See May 2019 VA Foot Conditions Examination DBQ. Again, the May 2019 examiner indicated no imaging studies were available. Id. Thus, the May 2019 medical opinion is considered inadequate for arthritis as well. Stefl, supra. A July 2019 foot examination report indicated that diagnoses of bilateral Morton’s neuroma occurred in 2014, metatarsalgia in 2019, hammertoes in 2018, hallux valgus in 1992 and 2019, and degenerative arthritis in 2018. The July 2019 examination report further indicated that the Veteran reported left foot burning, tingling, and shooting pain throughout all toes, swelling with ambulation difficulty after 5 minutes, and increased swelling, pain, and numbness with daily activities. Regarding the Veteran’s right foot complaints, the July 2019 examination report showed shooting, burning, and tingling pain in the plantar and dorsum areas with shooting pain from the tarsal extending into the foot while walking foot locks up. The Veteran further reported, in the July 2019 examination report, bilateral flare ups with increased swelling and throbbing pain with no medication relief. The July 2019 examination report indicated that the Veteran’s functional loss included the inability to walk, apply pressure, the need to alternate sitting and standing, along with walking in a left-foot boot and right foot surgical shoe. The July 2019 VA examiner found the Veteran’s neuroma and metatarsalgia remained painful in the plantar and dorsum areas, with difficulty flexing the great toe on the right foot, bilateral hammertoe in the little toes, and mild or moderate symptoms of bilateral hallux valgus. See July 2019 VA Foot Conditions Examination. Further, the July 2019 exam report specified that, upon examination, increased bilateral foot pain was noted on movement and weight and non weight-bearing, with contributing factors of functional loss including excess fatigability, swelling, and lack of endurance with interference with sitting and standing. However, the July 2019 examiner found the Veteran’s condition was not so severe that no effective function remained other than what would be equally served with amputation with prosthesis. Id. Additionally, the July 2019 examination report showed that a cane is used as an assistive device for the Veteran’s neuroma and bilateral hallux valgus. The July 2019 examiner reviewed the October 2018 bilateral foot x-rays with impressions of bilateral arthritis in midfoot areas and indicated the Veteran’s arthritis was service-connected, but provided a rationale that indicated no nexus was established. Id. Thus, this opinion is also inadequate regarding the Veteran’s bilateral foot arthritis. Stefl, supra The Board gives little probative value regarding the issue of bilateral arthritis to the July 2014, August 2016, January 2019, May 2019, and July 2019 medical opinions, as some were not aware of bilateral foot x-rays at the time of the examinations, and failed to discuss the existing x-rays. In January 2020, the Veteran underwent her sixth VA foot conditions examination. The 2020 examination report indicated that the Veteran described her bilateral foot pain with average daily right foot pain of 7 out of 10, on a 1 to 10 scale, and left foot pain as 11. The Veteran defined the pain as sharp, throbbing, stabbing, and, at times, dull and aching. See January 2020 VA Foot conditions DBQ. The January 2020 examination report further indicated that the Veteran reported flare-ups to occur daily, were severe, precipitated randomly or by standing, were alleviated by rest, with functional loss in the ability to stand, walk, jump, run, or drive for any length of time. Additionally, the January 2020 examination report confirmed the Veteran’s bilateral neuroma and metatarsalgia, and indicated under section x-foot injuries and other conditions that the Veteran’s residuals symptoms of her bilateral bunionectomy were moderately severe in severity. Further, the January 2020 examination report described the Veteran’s pain and weakness as due to her bilateral bunionectomy in 1992 and her additional left foot surgeries in 2014 and 2019. Upon examination, the January 2020 examination report showed the Veteran had functional loss and limitation of motion due to her bilateral foot pain on movement, weight-bearing and non weight-bearing, with excess fatigability and lack of endurance, which interferes with her ability to stand for daily normal activities related to daily living, to include prolonged standing and walking. See January 2020 VA Foot conditions DBQ. The January 2020 examiner found the Veteran’s condition was not so severe that no effective function remained other than what would be equally served with amputation with prosthesis. Id. The January 2020 examiner reviewed the August 2012 and December 2019 bilateral foot x-rays and found the Veteran has degenerative arthritis in her left foot only, further remarking the Veteran’s December 2019 left foot x-ray was negative for DJD, suggesting it was corrected with her 2014 and 2019 left foot surgeries. Id. As such, the Board finds the January 2020 VA medical opinion to have more probative value as it expresses with a degree of certainty that the August 2012 imaging studies were indicative of degenerative arthritis, even if corrected by April 2014 and March 2019 surgeries. As a result, the January 2020 medical opinion complied with the Board’s May 2019 Board remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Based on the above evidence, including VA examinations and treatment records, as well as the Veteran’s own description of bilateral foot pain with resulting limitation in functioning, the Board finds that a rating in excess of 30 percent under DC 5284 is not warranted. The Board further notes that the Veteran’s reports of pain, weakness, fatigability, and functional impairment are specifically encompassed in the assignment of the 30 percent disability rating. As described above, DC 5284 provides for ratings based on the overall severity of the disability. Overall, the Board finds that the Veteran’s bilateral symptomatology more nearly approximates that of a severe disability from the date of service connection. In reaching this conclusion, the Board finds probative the fact that the Veteran experienced foot pain aggravated by ambulation, which impacts her ability to sit and stand for prolonged periods and causes disturbance of locomotion. Thus, the Board finds that the Veteran’s disability picture more nearly approximates a 30 percent disability rating for the entire period under DC 5284 from the date of service connection. 38 C.F.R. § 4.7. The Board finds that a rating of 40 percent is not warranted as the evidence fails to suggest that the Veteran’s disability is analogous to actual loss of use of the foot, as it is clear that the Veteran’s bilateral feet are functional.38 C.F.R. § 4.71a, DC 5284, Note. Also, a separate rating under DC 5003, which pertains to degenerative arthritis, would violate the rule against pyramiding as the Veteran’s pain on use of her feet is already compensated under DC 5284, and a rating greater than 30 percent is not available under DC 5003. 38 C.F.R. § 4.14. Further, the Board does not find that rating the symptoms of pain under DC 5003, and the other non-pain symptoms under DC 5284, would result in a higher disability rating for the Veteran. Further, the evidence indicates that the Veteran has a diagnosis and mild symptoms of bilateral hallux valgus, post-surgical from her bilateral bunionectomy in 1992 and left side in 2019, and this diagnosis and symptoms are incorporated in her 30 percent disability rating under DC 5284. Thus, a separate rating under DC 5281, which pertains to hallux valgus, would violate the rule against pyramiding as the Veteran’s pain on use of her feet due to bilateral bunionectomy in 1992 and left side in 2019 are already compensated under DC 5284. 38 C.F.R. § 4.14. Additionally, the Veteran’s Morton’s neuroma is service-connected at 10 percent disabling, which is the highest rating. The Veteran’s bilateral hammertoe of her little toes are associated with her residuals of the bilateral bunionectomy and are service-connected at a non-compensable rating. Entitlement to a 10 percent disability rating would require all toes, unilateral without claw foot, which the Veteran’s medical records do not show, and she has not claimed to have. Additionally, the Veterans is service-connected for painful scars as residuals of the bilateral bunionectomy at 20 percent disabling, and would require five or more scars for a higher disability rating evaluation of 30 percent. 38 C.F.R. § 4.124a. For the foregoing reasons, the Board finds that a rating in excess of 30 percent is not warranted for the Veteran’s service-connected residuals of bilateral bunionectomy, to include degenerative arthritis. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. REASONS FOR REMAND 2. A rating in excess of 30 percent for vascular and tension headaches, prior to September 21, 2016, is remanded. In May 2020, the JMPR specifically found that the Board failed to ensure that VA satisfied its duty to assist the Veteran by obtaining any potentially outstanding VA treatment records. The May 2020 JMPR noted that the evidence of record contained records indicating scanned document[s] attached to notes, but without corresponding records contained within the Veteran’s claims file. See April 2014 Nursing Note indicating scanned documents; April 2014 anesthesia note indicating scanned documents; October 2013 MRI scanned note without underlying record. Additionally, the May 2020 JMPR found that the Board did not consider records that indicated that the Veteran’s headaches caused her to miss work, and thus, may have had the capability of producing economic inadaptability. See November 2014 VA Neurology Telephone Encounter Note; October 2014 Involuntary Termination Request from Comcast (employer indicating that the Veterans effectiveness to perform the job and efficiencies suffer due to her condition and that she was subject to corrective action due to the migraines); October 2014 Rehabilitation Needs Inventory (reporting daily headaches and missing work at times). Further, additional VA treatment records were added to the Veteran’s claims record in February 2019 from September 2007 to November 2015, which indicated headache treatment in 2012, with the Veteran reporting daily headaches, and migraines 2 to 3 times per week associated with nausea, and light and sound sensitivity, with medication not assisting. See August 2012 VA Primary Care Physician Note; September 2012 VA Nursing Telephone Encounter Note. Moreover, the August 2012 VA headache examination occurred less than 2 weeks after the August 2012 VA treatment wherein the examiner indicated no non headache symptoms such as nausea, light or sound sensitivity, etc. Thus, the Board finds an addendum opinion is necessary upon remand. Stegall, supra. Updated VA treatment records should also be secured. 3. Entitlement to a TDIU prior to May 12, 2016 is remanded. The issue of entitlement to a TDIU prior to May 12, 2016 is intertwined with the remanded increased rating claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The aforementioned matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Then obtain all outstanding VA treatment records which indicate “scanned documents attached to notes” that have not been associated with the record. See April 2014 Nursing Note indicating scanned documents; April 2014 Anesthesia note indicating scanned documents; October 2013 MRI scanned note without underlying record. To the extent there are documents existing in VistA imaging, these records should be associated with the Veteran’s claims file. If clarification is needed as to the records being requested, the Agency of Original Jurisdiction (AOJ) should consult the JMPR (labeled “CAVC Decision” and dated May 6, 2020). 3. Then obtain an addendum opinion from an examiner, other than the August 2012 and September 2016 VA examiners, to determine the nature, frequency, and severity of the Veteran’s service-connected vascular and tension headaches, prior to September 21, 2016, to include the question of whether the headaches resulted in very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. In addressing the above, please discuss: (1) the Veteran’s daily headaches and migraines 2 to 3 times per week and the sensitivity to sound and light with nausea; (see August 2012 VA Primary Care Note; August 2013 VA Primary Care Follow-Up; October 2013, July 2014 VA Neurology Outpatient Notes); (2) the Veteran’s statements indicating medications are ineffective such as Naproxen, Acetaminophen, Advil; Topamax, Topiramate, Sumatriptan Succinate (see August 2012 VA Primary Care Note; February 2014 VA Neurology Outpatient Note; March 2014 VA Outpatient Medications); (3) the Veteran indicating she has headaches all the time (see March 2014 VA Neurology Outpatient Note); (4) the Veteran’s statements regarding loss of work due to her severe headaches which may have the capability of producing economic inadaptability (see November 2014 VA Neurology Telephone Encounter Note; December 2014 VA Neurology Outpatient Note; October 2014 Involuntary Termination Request from Comcast (employer indicating that the Veterans effectiveness to perform the job and efficiencies suffer due to her condition and that she was subject to corrective action due to the migraines); October 2014 Rehabilitation Needs Inventory (reporting daily headaches and missing work at times); (5) the Veteran’s request for completion of FMLA documentation (see September 2014 VA Neurology Telephone Encounter Note); and (6) the MRI/MRA results (see October 2013, November 2013 VA Neurology Outpatient Notes). In addressing these questions, the examiner must assume items (1) and (5) as true, even despite the absence of “objective documentation.” Please state whether the Veteran’s vascular and tension headaches are “medically consistent” with the symptomatology reported by the Veteran in items (1) and (5) above. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the ability to provide the opinion is based on the limits of medical knowledge. 4. Then, readjudicate the remanded issues. E. BLOWERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Victoria L. Stephens 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.