Citation Nr: 21005850 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 15-33 779 DATE: February 2, 2021 REMANDED Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1962 through July 1965. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a September 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the claims file. This matter was previously before the Board in July 2019 and July 2020 and both times, was remanded for additional development. Unfortunately, upon review of the record, the Board finds that not all the July 2020 directives were completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the Board remanded the Veteran’s claim for entitlement to service connection for a headache disability to determine whether the Veteran has a current headache disability and if so, is it at least as likely as not the Veteran’s claimed headaches began in-service or are the result of the claimed head injury and tooth related incident the Veteran incurred in-service. The October 2020 VA addendum opinion noted the Veteran did not have a chronic diagnosis in-service, but did not discuss whether he has a current headache disability. Further, the October 2020 VA opinion relied on the January 2020 VA opinion in which the Board had already determined to be inadequate and insufficient. The Board notes the VA examiner stated the Veteran’s symptoms were self-report only. For headache disabilities, the Board recognizes that the Veteran is competent to report lay observable symptoms, such as headaches. The October 2020 VA examiner noted the Veteran’s reports of headaches are subjective, but did not discuss these subjective symptoms and did not state whether the Veteran has a current headache disability. It remains unclear to the Board whether the Veteran’s subjective symptoms are sufficient to form a diagnosis of a headache disability or an equivalent functional impairment as the VA examiner only discussed the Veteran’s service treatment records. Unfortunately, the Board finds the October 2020 VA addendum opinion did not comply with the July 2020 prior Board remand, a remand is necessary to ensure compliance with the remand’s directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes additional information was requested regarding the private records previously referenced by the Veteran in July 2020. The Veteran did not respond to the request. As the Board noted previously, such records may be important to the adjudication of his claim. Accordingly, as the case must again be remanded, the Board will afford the Veteran another chance to submit these records or to allow VA to obtain them on his behalf. The matter is REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain any records of his treatment for his claimed headache disability from any indicated private treatment provider. 2. Obtain an addendum opinion addressing the questions below. If the reviewing examiner determines that the opinions requested may not be offered without first examining the Veteran, please schedule a VA examination with an appropriate clinician. a) The examiner is asked to provide an opinion on whether the Veteran has a headache disability. In discussing whether the Veteran has a current headache disability, the examiner is asked to discuss and address the Veteran’s subjective report of symptoms and explicitly state what his symptoms are derived from, if not a headache disability. b) If a headache disability is diagnosed, is it at least as likely as not that the Veteran’s claimed headaches began in service or are the result of the claimed head injury and tooth related incident he had in service. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Mouzakis, 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.