Citation Nr: 21013764 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-15 522 DATE: March 10, 2021 REMANDED Entitlement to service connection for migraine headaches, to include as due to service-connected disability, is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to an initial disability rating in excess of 10 percent for the service-connected coronary artery disease (CAD) prior to November 18, 2011 is remanded. Entitlement to a disability rating in excess of 30 percent for the service-connected coronary artery disease (CAD) since November 18, 2011 is remanded. Entitlement to an earlier effective date, prior to November 18, 2010, for the award of service connection for coronary artery disease (CAD) is remanded. Entitlement to an earlier effective date, prior to November 18, 2011, for the award of service connection for bilateral hearing loss is remanded. Entitlement to an earlier effective date, prior to November 18, 2011, for the award of service connection for tinnitus is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1969 to November 1970. These matters come before the Board of Veterans’ Appeals (Board) on appeal from November and December 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously remanded by the Board in March 2018. 1. Entitlement to service connection for migraine headaches is remanded. Pursuant to the March 2018 Board remand, the Veteran underwent a VA headache examination in January 2020 and the examiner opined that the Veteran’s headaches were related to service. However, the examiner’s rationale was based on the Veteran having high risk factors based on service-connected and nonservice-connected disabilities, to include the service-connected posttraumatic stress disorder (PTSD), tinnitus and hypertension, which the examiner conclude may be related to his migraine headaches. The Board finds the opinion insufficient. In light of the above, an addendum opinion should be obtained upon remand. 2. Entitlement to service connection for a right knee disability is remanded. 3. Entitlement to an initial disability rating in excess of 10 percent for the service-connected coronary artery disease (CAD) prior to November 18, 2011 is remanded. 4. Entitlement to a disability rating in excess of 30 percent for the service-connected coronary artery disease (CAD) since November 18, 2011 is remanded. 5. Entitlement to an earlier effective date, prior to November 18, 2010, for the award of service connection for coronary artery disease (CAD) is remanded. 6. Entitlement to an earlier effective date, prior to November 18, 2011, for the award of service connection for bilateral hearing loss is remanded. 7. Entitlement to an earlier effective date, prior to November 18, 2011, for the award of service connection for tinnitus is remanded. Pursuant to the March 2018 Board remand, the Board noted that a full copy of the Veteran’s claims file has been lost, with only limited information available in the Veteran’s file dated before his November 2011 claims. The Board directed the RO to take all appropriate procedural actions to locate the Veteran’s claims file and inform the Veteran of all efforts to locate such information. The Board further instructed that if it is determined that the Veteran’s claims file remained lost, the RO was to undertake all procedurally appropriate actions to rebuild the missing contents of the Veteran’s file and such action should include providing specific notice requesting the Veteran provide copies of pertinent missing documents (or other information that may lead to obtaining a copy of missing documents) to assist in obtaining missing documents from other potential sources. All efforts to rebuild the missing contents of the claims file must be completed and documented in narrative form and associated with the claims file. The RO was instructed that documentation of the efforts to obtain missing contents and rebuild the missing contents of the claims file mist be associated with the claims file, and the Veteran must be informed of such efforts, and he must be informed which documents remain missing. However, the Board notes that upon review of the file, the Veteran was not informed of such information or efforts to rebuild his claims file. In this regard, per an October 2019 letter, the Veteran was notified that he may be able to furnish documents that can substitute for his STRs and VA also requested that he provide copies of all pertinent missing documents prior to November 2011 (or other information that may assist VA in obtaining a copy of missing contents) that may be in his possession. However, to date documentation in narrative form of all efforts to rebuild the missing contents of the claims file has not been completed; nor has the Veteran been informed of such efforts, to include informing him as to which documents remain missing. Accordingly, remand is required to document and notify the Veteran of all efforts to rebuild the missing contents of the claims file to fully comply with the Board’s March 2018 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding veterans are entitled to compliance with Board remand instructions). Updated treatment records should also be obtained upon remand. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. All efforts to rebuild the missing contents of the claims file in accordance with proper procedures must be completed and documented in narrative form and associated with the claims file. Documentation of the efforts to obtain the missing contents and rebuild the missing contents of the claims file must be associated with the claims file, and the Veteran must be informed of such efforts, and he must be informed which documents remain missing. 3. Send the Veteran’s claims file to the January 2020 VA headache examiner, if available, to obtain an addendum opinion regarding the etiology of the migraine headaches. If a new examination is required in order to respond to the request, such should be scheduled. Following review of the claims file, the examiner should provide an opinion as to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the migraine headache disability was caused by a service-connected disability, to include PTSD, tinnitus and/or hypertension? Please explain why or why not. (b.) If not caused by a service-connected disability, to include PTSD, tinnitus and/or hypertension, is it at least as likely as not that the Veteran’s migraine headache disability is worsened beyond natural progression (aggravated) by a service-connected disability, to include PTSD, tinnitus and/or hypertension? Please explain why or why not. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. The examiner is advised that a finding that the migraine headache disability was aggravated beyond the normal progression due to a service-connected disability does not require evidence of permanent worsening and may encompass any additional impairment in earning capacity resulting from an already service-connected condition. B. G. LeMoine Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Medina, 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.