Citation Nr: 21009068 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 14-31 944 DATE: February 18, 2021 REMANDED Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from August 1978 to August 1981. This matter comes before the Board of Veterans Appeals (Board) on appeal from a December 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The case was previously remanded by the Board for further development in May 2018 and June 2020. Unfortunately, it is necessary to remand for a third time. When a case is remanded, a veteran is entitled to substantial compliance with all remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). If the RO does not substantially comply with the Board’s remand instructions, the Board is legally bound to continue remanding until the mistake is corrected. See id. In July 2020, the Board remanded based on a finding that the February 2020 VA examination, which the RO relied upon when denying the Veteran’s claim, was inadequate. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Specifically, the Board had this to say about the February 2020 examiner’s opinion: The examiner noted, in part, that the Veteran’s headaches started about 5 years ago [in 2015]. However, upon review of the record, the Board finds that this opinion does not reflect consideration of Veteran’s full medical history or the record as a whole. Specifically, May 2005 VA treatment records note that the Veteran complained of a mild frontal headache. Further, VA received a written correspondence from the Veteran in May 2009 in which he stated that he had been experiencing migraine headaches at least two or three times a week. A medical examiner is not required to provide a detailed review of the Veteran’s complete medical history or comment on every piece of favorable evidence in the record; however, the opinion must reflect consideration of the Veteran’s medical history so that the Board’s evaluation of the claimed disability is fully informed. Monzingo v. Shinseki, 26 Vet. App. 97, 105-07 (2012); Stefl v. Nicholson, 21 Vet. App.120, 124 (2007). As this opinion does not reflect consideration of the Veteran’s full medical history, an additional opinion must be obtained. In October 2020, following this remand, the Veteran was given a new VA examination. Unfortunately, the October 2020 VA examiner’s opinion is nearly identical to the February 2020 opinion, and inadequate in the exact same ways. Compare the rationale of the February 2020 opinion: [T]here are no findings of a TBI and no findings in the STR of headaches or head injury, Separation exam 9/3/81- no complaint of head injury, loss of consciousness or memory loss, or headaches, and per history his headaches started about 5 years ago To that of the October 2020 opinion: Veteran does not have documentation to support TBI diagnosis. The headache is not a residual from head injury since there is no documented head injury. There are minimal notes to support headaches in service. Veteran service was from 1978-1981. Veteran states headache started in 2015 - which is many years after service Once again, the most recent examiner has failed to address evidence in the record that the Veteran began experiencing headaches prior to 2015. VA Treatment records show that the Veteran has taken medication for headaches since at least October 2004, that he presented to the emergency room complaining of a headache in May 2005, and that he complained of recurring nighttime headaches in June 2011. In a letter addressed to VA in May 2009, the Veteran alleged he had been having “severe” headaches since his tour of service. This very claim has been before the Board since 2011, and the Veteran first sought service connection for headaches in 2009. The Board cannot accept a medical opinion that states the Veteran has only experienced headaches “since 2015,” without mentioning any of this evidence. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, regarding the nature and etiology of the Veteran’s headache disability. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s headache condition had its onset in service, or is otherwise related to an in-service injury, disease, or event? (b) Is it at least as likely as not that the Veteran’s headache condition had its onset within one year of separation? (c) If the Veteran’s headaches are unrelated to his military service, what is the likely etiology of his headache disability? The examiner must review the entire claims file, and the opinion must reflect consideration of Veteran’s full medical history and the record as a whole. The examiner should specifically address the Veteran’s May 2009 statement regarding his headaches, and his headache complaint in 2005. (Continued on the next page) 2. The Agency of Original Jurisdiction must review the examination report to ensure that the requested opinions comply with the above remand directives. If an opinion is deficient in any manner, the Agency of Original Jurisdiction must undertake corrective action before returning the case to the Board. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shermila Sundquist 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.