Citation Nr: 21012830 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 17-13 978A DATE: March 5, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim of service connection for headaches is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for posttraumatic stress disorder (PTSD) is granted. Service connection for PTSD is granted. Service connection for fibromyalgia is granted. Service connection for pulmonary embolism is denied. Service connection for memory loss is denied. REMANDED The issue of service connection for low back disability is remanded. The issue of service connection for headaches is remanded. FINDINGS OF FACT 1. An August 2015 rating decision denied service connection for headaches. Although the Veteran was notified of the RO’s decision and his appellate rights, he did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of the issuance of that decision. 2. The evidence received since the final August 2015 rating decision includes evidence which relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection. 3. A June 2015 rating decision denied service connection for PTSD. Although the Veteran was notified of the RO’s decision and his appellate rights, he did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of the issuance of that decision. 4. The evidence received since the final June 2015 rating decision includes evidence which relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection. 5. The Veteran’s PTSD is related to his active service. 6. The Veteran, who served in the Southwest Asia theater of operations during the Persian Gulf War, has a diagnosis of fibromyalgia. 7. The Veteran’s pulmonary embolism was not shown as chronic in service; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease, to include service in Southwest Asia theater of operations during the Persian Gulf War. 8. The preponderance of the evidence of record is against finding that the Veteran has had memory loss at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The August 2015 rating decision denying service connection for headaches is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 3.104, 20.302, 20.1103. 2. New and material evidence has been received to reopen the previously denied claim of service connection for headaches. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302. 3. The June 2015 rating decision denying service connection for PTSD is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 3.104, 20.302, 20.1103. 4. New and material evidence has been received to reopen the previously denied claim of service connection for PTSD. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302. 5. The criteria for service connection for PTSD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125(a). 6. The criteria for service connection for fibromyalgia have been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 7. The criteria for service connection for pulmonary embolism have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 8. The criteria for service connection for memory loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1981 to July 1984 and November 1990 to May 1991. The Veteran participated in Operation Desert Shield/Storm from November 1990 to May 1991. He received the Combat Action Ribbon. These matters come before the Board of Veterans’ Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) issued in June 2013 and November 2017. The Veteran submitted Notices of Disagreement (NODs) in September 2013 and in January 2018 respectively. Statements of the Case (SOCs) were issued in February 2017 and in January 2020. The Veteran perfected the appeal by submitting timely VA Form 9s in March 2017 and in March 2020. The Veteran and his spouse testified at a January 2021 Board hearing. A transcript of that hearing has been associated with the record. New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. See 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims such as this one, filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening the claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence related specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Id. at 118. Factual Background In June 2015, the RO denied service connection for posttraumatic stress disorder. The RO conceded that the Veteran experienced a stressful event in service or fear of hostile military or terrorist activity but found that the Veteran was not diagnosed as having PTSD. The Veteran was notified of the decision and his appellate rights in a June 2015 letter. The Veteran did not submit new evidence or an NOD in the prescribed time period and the June 2015 rating decision became final. In August 2015, the RO denied the Veteran’s claim of service connection for headaches as due to an undiagnosed illness. The RO found that the Veteran’s service treatment records did not contain complaints, treatment, or diagnosis for headaches that the Veteran was diagnosed as having. The RO also did not find a link between the Veteran’s headaches and his service, to include service in the Southwest Asia theater of operations during the Gulf War. The Veteran was notified of the decision and his appellate rights in a September 2015 letter. The Veteran did not submit new evidence or an NOD in the prescribed time period and the August 2015 rating decision became final. In August 2017, the Veteran resubmitted his claim of service connection for headaches and PTSD. In November 2017, the RO reopened the Veteran’s claims, but found that the Veteran’s headaches and PTSD were not related to his service. The RO found that the Veteran’s PTSD and headaches were not related to service and that headaches were not a qualifying disability associated with Gulf War service. The Veteran submitted an NOD in January 2018. In June 2019, the Veteran submitted a private medical opinion that diagnosed the Veteran as having PTSD based on DSM-V. In January 2020 an SOC was issued continuing the denial. The Veteran submitted a VA Form 9 in March 2020. In January 2021, the Veteran submitted statements from family and friends describing his PTSD symptoms. At the January 2021 hearing, the Veteran testified that the prior VA examination for PTSD was cursory and that it did not reflect the Veteran’s combat decoration. The Veteran stated that he experienced symptoms of anger, nightmares, and other sleep troubles since service and his spouse testified that the Veteran tended to withdraw if there was too much happening. Regarding his headaches, the Veteran testified that the headaches were associated with both physical and psychological stress, to include PTSD. 1. Whether new and material evidence has been received to reopen the previously denied claim of service connection for headaches 2. Whether new and material evidence has been received to reopen the previously denied claim of service connection for PTSD In this appeal, the Veteran seeks to reopen his claim of service connection for headaches and PTSD. As noted above, despite the finality of a prior adverse decision, a claim will be reopened, and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Since the last prior final decision in June 2015 and August 2015, additional evidence has been added to the record, as listed above. Specifically, the Veteran’s testimony regarding the potential causes of his headaches, to include fibromyalgia and/or PTSD, presents material evidence relating to an unestablished fact necessary to substantiate the claim of service connection for headaches. Regarding PTSD, the private diagnosis of PTSD presents material evidence relating to an unestablished fact necessary to substantiate the claim of service connection for headaches. Therefore, new and material evidence have been received since the final rating decisions and the prior final disallowance of the claims of service connection for headaches and PTSD are re-opened. Service Connection. Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. Id.; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). “It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran.” Gilbert, 1 Vet. App. at 54. 3. Service connection for PTSD The Veteran contends that he is currently diagnosed as having PTSD and that it was caused by his active service. Service connection for posttraumatic stress disorder (PTSD) requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The medical evidence diagnosing PTSD must be in accordance with 38 C.F.R. § 4.125(a), which refers to the American Psychiatric Association Diagnostic and Statistical Manual for Mental Disorders (DSM) as the source of criteria for the diagnosis of claimed psychiatric disorders. The Board notes that DSM-V is the updated version of the Fourth Edition (DSM-IV). The DSM-V applies to all claims received on or after August 4, 2014. In this case, the Veteran’s claim was received after that date, in August 2017. Thus, the DSM-V applies. The Court of Appeals for Veterans Claims (Court) has held the Board should not rely on DSM-IV findings when DSM-V applies. Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). The preponderance of the evidence supports a causal link between the Veteran’s PTSD and his active service. In June 2019, a private medical practitioner diagnosed the Veteran as having PTSD and opined that the stressors causing the Veteran’s PTSD were from his service in Southwest Asia. Specifically, the Veteran reported that he saw bodies and people burning in “up on the Highway of Death.” The Veteran served in combat. The private medical practitioner found that the Veteran directly experienced the traumatic events, witnessed them in person, and that he otherwise met the DSM-V criteria for PTSD. Although the March 2015 VA examiner did not diagnose PTSD or any other mental disorder, greater probative weight is assigned to the June 2019 private medical opinion. Specifically, the March 2015 VA examination did not include any discussion of the Veteran’s combat service. The March 2015 VA examination is also inadequate as it was thus based on incomplete factual bases. For the foregoing reasons, service connection for PTSD is granted. Medically Unexplained Chronic Multisymptom Illness (MUCMI) Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf Veteran who exhibits objective indications of a “qualifying chronic disability” that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1)(i); See 81 Fed. Reg. 71,382, 71,383 (Oct. 17, 2016). A Persian Gulf Veteran is defined as a Veteran who served on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C. § 1117(f); 38 C.F.R. § 3.317(d). The Southwest Asia theater of operations is defined as Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). Service department records reflect that the Veteran had active duty service in Southwest Asia. A “qualifying chronic disability” means a chronic disability resulting from: an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI) that is defined by a cluster of signs or symptoms (such as chronic fatigue syndrome (CFS), fibromyalgia, or functional gastrointestinal disorders). 38 C.F.R. § 3.317(a)(2)(i). Chronic in this context is defined as existing for six months or more and/or exhibiting intermittent episodes of improvement and worsening over a six-month period. See 38 C.F.R. § 3.317(a)(4). In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. Signs or symptoms which may be manifestations of an undiagnosed illness or a MUCMI include, but are not limited to fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). 4. Service connection for fibromyalgia The Veteran contends that he has a current diagnosis of fibromyalgia that persisted for more than 6 months since service. The record contains a competent diagnosis of fibromyalgia. VA Medical Center treatment records show that the Veteran had symptoms suggestive of fibromyalgia from December 2015 and that he was finally diagnosed as having fibromyalgia in January 2019. The Board, accordingly, finds competent evidence of a current disorder. Fibromyalgia is included in the list of disorders that qualify as a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms. 38 C.F.R. § 3.317(a)(2)(i). Service connection is therefore warranted, as fibromyalgia is presumed to be related to the Veteran’s service in the Southwest Asia theater of operations. See 38 C.F.R. § 3.317. 5. Service connection for pulmonary embolism The Veteran contends that his pulmonary embolism was caused by his active service, to include his service in the Southwest Asia theater of operations during the Persian Gulf War. He also contends that his pulmonary embolism, or blood clots, is a medically unexplained multisystem chronic illness. Factual Background Service treatment records do not show any complaints, treatment, or diagnoses of pulmonary embolism. Medical examination from November 2004 show that the Veteran did not report any abnormalities although he reported that he has various other ailments. Private medical treatment records show that the Veteran was diagnosed as having bilateral lower lobe pulmonary emboli in October 2006. The Veteran reported that he had pulmonary function tests 4 weeks prior to complete an application to the police academy. The Veteran reported that he developed pain in his joints 2 weeks prior after driving and being on an airplane. Prior to developing these symptoms, the Veteran described himself as active and that he worked as a contractor. The diagnoses were acute respiratory failure, pulmonary emboli, pulmonary infarcts, lupus anticoagulant, and recent rash after taking Valtrex. In March 2008, a private medical practitioner stated that the Veteran was “vigorously healthy and exercised quite a bit” and that the bilateral pulmonary emboli began while running on the beach in 2006. The practitioner stated that the Veteran was on Coumadin since 2006. The Veteran presented “with what sounds like a deep venous thrombosis of his lower extremity and eventuated in bilateral pulmonary emboli.” The Veteran’s history of a lupus anticoagulant was also noted, and the private practitioner stated that Lupus coagulant is an acquired antiphospholipid antibody, which predispose men to venous thromboembolism. In June 2013, the Veteran was afforded a VA examination for his pulmonary embolism. The examiner opined that it was less likely than not connected to his service based on the lack of treatment records during service and noted that the first diagnosis was made in 2006. In January 2015, a private medical practitioner speculated that there could be a connection between the Veteran’s Gulf War Service and his portal vein thrombosis given the “apparent lack of provocation leading to mesenteric/portal vein thrombosis and the [pulmonary embolism] that occurred after a short plane flight.” The practitioner, however, based this speculation on the assumption that Veterans from the Gulf War have a higher incidence of thrombophilia and did not cite the source of the assumption. The Veteran was afforded another VA examination in March 2015. The examiner opined that the pulmonary embolus was a result of trauma and prolonged immobilization as well as antiphospholipid antibodies rather than the Veteran’s active service. The rationale was that there were no health problems associated with depleted uranium exposure found in veterans who were exposed to depleted uranium. The examiner also stated that the Veteran’s antiphospholipid antibody was an autoimmune disease that was not related to a specific exposure event such as burn bits or burning oil experienced by the Veteran during service in Southwest Asia. The examiner further explained that the medical literature found inadequate or insufficient evidence of an association between exposure to combustion products and cancer, respiratory disease, circulatory disorders, neurologic disease, and adverse reproductive and developmental outcomes in the population studies. The limitation of the study, according to the examiner, was that the report did not yield conclusive results about the health effects associated with burn pit exposure. In a February 2017 SOC, the RO continued its denial of service connection for pulmonary embolism, to include portal vein blood clots, as there was no nexus to service. The RO also stated that pulmonary embolism and portal blood vein clots were distinct diagnoses and therefore could not be considered as “undiagnosed illnesses.” In January 2021, the Veteran’s representative contended that the blood clots were a symptom and that they had to be viewed as medically unexplained multisystem chronic illness as different medical providers indicated that they had no idea what it was. The Veteran testified that he stopped using the anticoagulant to get into the State Police. Analysis After considering the evidence of record, the Board concludes that the most probative evidence establishes that the Veteran’s current pulmonary embolism, or blood clots, is not causally related to his active service or any incident therein, to include service in the Southwest Asia theater during the Gulf War. As discussed above, the Veteran has a current diagnosis of pulmonary embolism, or thrombosis. Contrary to the Veteran’s contentions of it being a symptom of a MUCMI or of unknown etiology, the medical opinion of record show that they were due to the Veteran’s acquired antiphospholipid antibody, which predispose men to venous thromboembolism. In addition to identifying the etiology of the Veteran’s pulmonary embolism, the March 2015 VA examiner explained that the Veteran’s active service and exposure to depleted uranium, burn bits, and other environmental hazards were less likely than not the cause of pulmonary embolism. The Board finds that the March 2015 VA examination to be adequate, based on a thorough review of the record including a discussion of the private treatment records and supported with rationale. Although a private practitioner discusses the possibility of a causal relationship between the Veteran’s service and his pulmonary embolism in January 2015, the Board observes that the private practitioner did not offer an etiological opinion and merely entertained a possibility. The possibility was also based on the assumption that medical literature existed suggesting a higher incidence of pulmonary embolism (or thromboembolism) among Gulf War veterans. The private practitioner did not cite the medical literature on which the assumption was based. Even if the existence of such medical literature is assumed, the private practitioner only stated that it was a possibility, and is outweighed by the March 2008 private practitioner’s opinion and the March 2015 VA examiner’s opinion that both attributed the Veteran’s pulmonary embolism and blood clots to his acquired antiphospholipid antibody. Moreover, to the extent the Veteran asserts that a relationship exists between his pulmonary embolism and his service in the Southwest Asia theater of operations during the Persian Gulf war, the Board finds that such assertions do not provide persuasive evidence in support of the claim. The matter of the medical etiology of the disability here at issue is one within the province of trained medical professionals. Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Although lay persons are competent to attest to matters within their own personal knowledge, to include symptoms experienced or observed (as appropriate), as well as to provide opinions on some medical issues, such as those perceived through the senses (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), here, the etiology of the Veteran’s pulmonary embolism is a complex medical matter that falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, lay assertions as to the etiology of the Veteran’s pulmonary embolism have no probative value. In summary, the absence of competent medical or scientific evidence documenting a relationship between the Veteran’s pulmonary embolism and his service, service connection on a direct basis must be denied. Therefore, the evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54. The preponderance of the evidence is against the Veteran’s claim, and as such entitlement to service connection for pulmonary embolism is denied. 6. Service connection for memory loss The Veteran contends that he has memory loss that is caused by his service, to include his service in the Southwest Asia theater of operations during the Persian Gulf War. The most probative evidence establishes, however, that the Veteran does not have memory loss and has not had memory loss at any time during the pendency of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). There is no medical evidence of record that diagnosed the Veteran as having memory loss, or even a symptom of memory loss. Service treatment records do not show the Veteran complaining of memory loss during service. In March 2011, the Veteran did not report any difficulties with concentration or memory. During a VA examination for mental disorders in March 2015, the Veteran complained of poor memory. The Veteran, however, reported that it did not affect his business as he had done it for so long. When asked directly to do “three objects,” the Veteran said that he could not remember at all. The Veteran, however, was able to recall information when asked indirectly, such as the examiner’s name. VA Medical Center treatment records since the VA examination show the Veteran complaining of memory loss. A private practitioner in June 2019, however, did not find symptoms of memory loss after diagnosing the Veteran as having PTSD. The practitioner noted that the Veteran had fair concentration with short attention span and opined that the Veteran’s memory was “broadly intact.” At the January 2021 hearing, the Veteran testified that his memory loss bothered him during an examination at the VA Medical Center. The Veteran, however, did not testify on other instances of memory loss or its effects on his daily life. The Veteran also did not show any difficulty remembering events related to his other disabilities and symptoms, and recalled the time and place of his injuries, treatments, and diagnoses. The statements from the Veteran’s friends and family describing his symptoms also did not discuss memory loss although other symptoms, such as anger, frustration, and difficulty with sleep were consistently mentioned. In summary, there is no evidence of a current disability, in this case memory loss, and the first of the three requirements for service connection is not met. See Shedden, 381 F.3d at 1167. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND 1. The issue of service connection for low back disability is remanded. 2. The issue of service connection for headaches is remanded. The Veteran contends that his low back disability and headaches are caused by his service in the Southwest Asia theater of operations during the Persian Gulf War, to include as due to fibromyalgia and PTSD. As indicated above, service connection for fibromyalgia and PTSD have been granted herein. It is unclear form the evidence of record whether the Veteran’s low back disability and/or headaches are symptoms of fibromyalgia and/or PTSD or separate disabilities. The Veteran testified that his low back hurt when he had muscle pain and other symptoms of fibromyalgia, and that his headaches appeared after physical or psychological stress, suggesting that either or both could be symptoms of the service-connected disabilities. Medical treatment records, however, showed that the Veteran reported he had headaches since 2005 and back pain since 2006, suggesting that these disabilities could also be separate from fibromyalgia and PTSD. VA examination from June 2013 did not diagnose the Veteran as having a back disability and opined that the Veteran’s back pain was not related to service. The examiner did not opine on whether the Veteran’s back pain was related to the Veteran’s fibromyalgia as the Veteran had not been diagnosed as having fibromyalgia at the time. A VA examination from March 2015, however, showed that the Veteran has “rotation or mild scoliosis of the spine” during a VA examination for the Veteran’s pulmonary embolism but again did not diagnose the Veteran as having a back disability nor opine on the etiology of the Veteran’s low back pain. Regarding the Veteran’s headaches, the March 2015 VA examination was both ambiguous and inadequate as it did not address secondary causation. The examiner, although diagnosing a “typical headache,” also noted that the Veteran did not experience headache pain and opined that it was not related to a specific exposure event in Southwest Asia. There was no opinion on whether the Veteran’s headaches were caused or aggravated by fibromyalgia or PTSD as, again, the Veteran had not been diagnosed as having fibromyalgia or PTSD at the time of the March 2015 VA examination. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (holding that secondary service connection is a two-part issue that involves causation and/or aggravation); 38 C.F.R. § 3.310 (providing that “[a]ny increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected”). Accordingly, it necessary to remand the Veteran’s claims of service connection for low back disability and headaches for additional development. Once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of low back disability. The examiner should review the virtual file. The examiner is to address the following: (a) State whether disability of the low back is currently present or if it is a symptom of another disability, to include service-connected fibromyalgia. If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. (b) Whether it is at least as likely as not (50 percent or greater probability) that a low back disability, if diagnosed, manifested during or is otherwise related to the Veteran’s period of active service. (c) Whether it is at least as likely as not (50 percent or greater probability) that a low back disability, if diagnosed, was caused or aggravated by a service-connected disability, to include fibromyalgia. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of headaches. The examiner should review the virtual file. The examiner is to address the following: (a) State whether headaches are currently present or if they are a symptom of another disability, to include service-connected fibromyalgia and/or PTSD. If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. (b) Whether it is at least as likely as not (50 percent or greater probability) that headaches, if diagnosed, manifested during or is otherwise related to the Veteran’s period of active service. (c) Whether it is at least as likely as not (50 percent or greater probability) that headaches, if diagnosed, was caused or aggravated by a service-connected disability, to include fibromyalgia and/or headaches. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Yun 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.