Citation Nr: 21013655 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 13-27 690 DATE: March 10, 2021 REMANDED Entitlement to an initial evaluation in excess of 30 percent for tension headaches since May 3, 2013 is remanded. Entitlement to an initial evaluation in excess of 10 percent for left hip strain since May 3, 2013 is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2008 through January 2012. These claims come before the Board of Veterans’ Appeals (Board) on appeal from May 2012 and June 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In June 2019, the Board issued a decision which denied entitlement to an initial evaluation in excess of 30 percent for tension headaches since May 3, 2013, entitlement to an initial evaluation in excess of 10 percent for left hip strain since May 3, 2013 and entitlement to a TDIU. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In response to the appeal, the Court issued an Order granting a Joint Motion for Remand (JMR) by the parties which vacated the June 2019 Board decision and remanded the issues for readjudication. See June 2020 Order. 1. Entitlement to an initial evaluation in excess of 30 percent for tension headaches since May 3, 2013 and entitlement to an initial evaluation in excess of 10 percent for left hip strain since May 3, 2013 As discussed in the June 2020 JMR, the Board remanded these claims in August 2017 for a new VA medical examination to determine the severity and manifestations of the Veteran’s service-connected tension headaches and left hip strain. The Veteran attended VA examinations for both disabilities in January 2019. However, the examiner failed to provide opinions as to the severity and manifestations of either of the serviced-connected conditions, explaining only that due to the Veteran’s mental health condition, he was incompetent for evaluation. The JMR agreed that the lack of detail rendered these examinations inadequate for rating purposes. Consistent with the instructions in the June 2020 JMR, the Board finds that a new medical examination is necessary for both the Veteran’s tension headaches and left hip strain so that an examiner may provide the required information that will allow the Board to assign a rating which accurately reflects the severity and manifestations of the disabilities present. 2. Entitlement to a TDIU Finally, because a decision on the remanded issues of entitlement to increased initial evaluations for the Veteran’s tension headaches and left hip strain could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU is thus also required. The matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination by an appropriate clinican to determine the current severity of his tension headaches. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. Specifically, the examiner should state whether the Veteran suffers characteristic prostrating attacks, and comment on the frequency and severity of such attacks. The VA examiner should further include a statement of the effect of the Veteran’s migraine headaches on his occupational functioning and daily activities. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his left hip strain. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). In so doing, the examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must 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), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Lastly, the VA examiner should include a statement of the effect of the Veteran’s left hip strain on his occupational functioning and daily activities. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to a TDIU. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Churchwell, 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.