Citation Nr: 21009164 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 14-22 618 DATE: February 19, 2021 REMANDED Entitlement to service connection for migraine headache, to include as secondary to service-connected residuals of exostosis removal surgery on the upper arm, is remanded. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected residuals of exostosis removal surgery on the upper arm, is remanded. Entitlement to service connection for right shoulder disability, to include as secondary to service-connected residuals of exostosis removal surgery on the upper arm, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1963 to July 1967. This case was remanded in April 2019. 1. Service connection for migraine headache 2. Service connection for fibromyalgia 3. Service connection for right shoulder disability The Veteran maintains that his diagnosed migraine headaches, fibromyalgia, and right shoulder disabilities were either caused or aggravated by his service connected residuals of exostosis removal surgery on the upper arm. The Veteran underwent a VA examination in January 2013, where the examiner concluded that service-connected residuals of upper arm surgery to remove exostosis did not cause migraine headache, fibromyalgia, and right shoulder disability. The opinion, however, did not address whether these conditions were aggravated by the Veteran’s service-connected disability. In April 2019, the Board remanded the claims to obtain an adequate opinion. A VA examiner in November 2019 concluded that it is less likely as not that his migraine headaches, fibromyalgia, and right shoulder disabilities were either caused or aggravated by his service connected residuals of exostosis removal surgery on the upper arm. The opinions regarding migraine headaches and fibromyalgia are entirely conclusive and offers no medical guidance as to the basis of the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, the VA examiner, in providing the rationale, was unable to confirm the Veteran’s reports of falling from a horse, although it is clearly documented in the service treatment records. See April 1964 service treatment record. A medical opinion based on an incorrect history is inadequate. Further opinion is needed. The matters are REMANDED for the following action: 1. Update VA treatment records. 2. Thereafter, forward the e files to appropriate VA medical professional and ask that he or she submit an addendum statement indicating the likelihood that the Veteran’s migraine headaches, fibromyalgia and/or right shoulder disabilities are related to military service, This includes whether the service-connected residuals of exostosis removal surgery on the upper arm has either (a) caused or (b) aggravated his migraine headaches, fibromyalgia and/or right shoulder disabilities. In providing the rationale, the examiner should comment on the statements of the Veteran. In reviewing the relevant records, it is noted that a fall from a horse is noted in the Veteran’s service treatment records. It may be necessary to have the Veteran reexamined, but this is left to the examiner’s discretion as to whether another examination is needed to make these determinations. Nathaniel Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.D. Jackson, 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.