Citation Nr: 21022224 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 17-03 188 DATE: April 15, 2021 REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for residuals of a head injury is remanded. REASONS FOR REMAND This case was previously before the Board in December 2018, when service connection for diabetes mellitus, an acquired psychiatric disorder, and residuals of a head injury was denied. The Veteran appealed the case to the United States Court of Appeals for Veterans Claims (Court), where the parties filed a Joint Motion for Remand (JMR). In November 2019, the Court granted the JMR, vacating the portion of the Board decision denying service connection for these disabilities, and remanding the case for further proceedings. The case has been returned to the Board at this time for further appellate review. 1. Entitlement to service connection for diabetes mellitus is remanded. 2. Entitlement to service connection for an acquired psychiatric disorder is remanded. In a March 2021 telephone call, the Veteran reported that he has been treated for disabilities related to this appeal at VA medical facilities, and requested that these recent records be associated with the claims file. Therefore, a remand is necessary to obtain these records. See Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016) (where Veteran “sufficiently identifies” other VA medical records that he or she desires to be obtained, VA must also seek those records); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). The record also reflects the Veteran may have private treatment records relevant to his appeal. On remand, his authorization should again be requested so that VA may attempt to obtain these on his behalf. 3. Entitlement to service connection for residuals of a head injury is remanded. On remand, the Board finds a new opinion regarding service connection for residuals of a head injury is necessary. The Board previously directed the RO to obtain an opinion determining whether the Veteran has any current disorders as a result of a head injury, to include intermittent headaches or pain in the left temple. The examiner was asked to consider the Veteran’s assertions that he has a throbbing pain in his left temple as a result of being a boxer in the Navy, and of VA treatment records showing complaints of headaches in the left side of the head. The RO obtained VA examinations in August 2020, in which the examiner identified a nummular headache disorder, but opined that the Veteran did not experience a traumatic brain injury during service. The examiner opined that the current nummular headaches are not related to service because there is no documentation of a headache syndrome while in service, and because there was no evidence of a traumatic brain injury during service. The examiner did not address whether any current residual could be due to head trauma experienced in service that did not result in traumatic brain injury. Further, the examiner only addressed the Veteran’s reports that he experienced headaches during service to the extent these were documented in the service treatment records; that is, the examiner did not address the Veteran’s reports that he experienced headaches more regularly than he sought treatment for during service, and that he continued to experience headaches, although to a lesser degree, after separation from service and continuing to the present. In other words, the examiner appears to have impermissibly dismissed the Veteran’s reports of continuous headaches solely because these complaints were not documented in medical treatment records. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). For these reasons, the Board finds this opinion to be inadequate, and a new opinion should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain any and all VA treatment records from the Tennessee Valley VA Medical Center, including the Chattanooga CBOC, and/or any other VA medical facility that may have treated the Veteran, and associate those documents with the claims file. 2. Ask the Veteran to identify any private treatment that he may have had for his psychiatric disorder(s), diabetes mellitus, and head injury residuals. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records on his own behalf. 3. Then, forward the claims file to an appropriate clinician to determine whether any current residual of a head injury, including but not limited to nummular headache disorder, is related to the Veteran’s military service. Following review of the claims file, the examiner should identify all residuals of a head injury or headache-related disorders currently found, to include the entire period of the pendency of this appeal, since approximately October 2014. In the context of identifying current residuals and disorders, the examiner is asked to discuss whether any residuals may occur from head trauma that does not result in traumatic brain injury. For EACH current residual or disorder identified, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. In providing the requested opinions, the examiner should specifically address the Veteran’s lay statements regarding his activities as a boxer during service, as well as his statement regarding the onset and continuity of headache symptoms. The examiner may not dismiss reports of headaches during service based SOLELY on a lack of contemporaneous medical documentation. (Continued on next page)   All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. E. Choi Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Josey, 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.