Citation Nr: 21026613 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 17-17 620 DATE: May 3, 2021 REMANDED Entitlement to service connection for degenerative changes of the left hip is remanded. Entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran had active duty service from February 1966 to November 1969. This case is before the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In December 2019, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of his testimony is associated with the claims file. In March 2020, the Board remanded this claim for additional development. 1. Entitlement to service connection for degenerative changes of the left hip is remanded. The Veteran and representative assert that his left hip disability originated due to an injury he experienced during his active duty service. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. During the December 2019 Board hearing the Veteran provided sworn testimony and explained the circumstances around his in-service injury. The Veteran explained that he did not seek medical treatment during service for his hip injury. As the Veteran is competent to report that which he perceives through his symptoms, the Board finds this sworn statement to be competent and credible to report what he witnessed first-hand during his active duty service. Layno v. Brown, 6 Vet. App. 465 (1994). In March 2020, the Board remanded this claim to afford the Veteran a VA examination. In April 2020, the Veteran was examined by a VA examiner. The VA examiner determined that the Veteran had a diagnosis of left hip arthritis. However, the examiner concluded that the left hip disability was not related to service as it had been more than 50 years since separation from service. The RO subsequently requested that the examiner elaborate further regarding the rationale. In September 2020, the examiner submitted an addendum opinion in which he noted that the Veteran was credible, however he is not considered "creditable" to diagnose himself with a hip condition. The RO requested yet another addendum opinion explaining that the current hip disability is less likely than not related to service. The Board finds that the examiner relied on the lack of treatment post service and disregarded the Veteran's reported, though not documented, history of hip pain. The Board finds that the VA examiner's opinion is inadequate, and another opinion is needed. 2. Entitlement to service connection for migraine headaches is remanded. The Veteran and representative assert that his migraine headaches originated in active duty service. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. During the December 2019 Board hearing the Veteran provided sworn testimony and explained the onset of symptoms during his active duty service. The Veteran explained that he did seek medical treatment from a corpsman, but the condition was incorrectly diagnosed as sinusitis. The Board observes that there are sinusitis complaints in the Veteran's service treatment records. As the Veteran is competent to report that which he perceives through his symptoms, the Board finds this sworn statement to be competent and credible to report what he witnessed first-hand during his active duty service. Layno v. Brown, 6 Vet. App. 465 (1994). In March 2020, the Board remanded this claim to afford the Veteran a VA examination. In April 2020, the Veteran was examined by a VA examiner. The VA examiner determined that the Veteran had a diagnosis of headaches. However, the examiner concluded that the headache disability was not related to service as it was not diagnosed until an examination dated in June 2018. The RO subsequently requested that the examiner elaborate further regarding the rationale. In September 2020, the examiner submitted an addendum opinion in which he noted that the Veteran was a "creditable" source but lacked the evidence to support that his disability originated in service, since his disability was first diagnosed in 2018. The RO requested yet another addendum opinion explaining that the current headache disability is less likely than not related to service. The Board finds this opinion is clearly inadequate, as there are treatment records for his long-standing migraine headaches dating back to 1983, therefore the disability did not originate in June 2018. As the opinion was clearly inadequate, another opinion is necessary by a VA examiner with appropriate expertise to determine the nature and etiology of the Veteran's disability. The matters are REMANDED for the following action: 1. Afford the Veteran a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's migraine headaches. Any and all tests, studies, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, and private medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: a. Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's migraine headaches originated during, or is etiologically related to, active duty service. b. The examiner is also asked to specifically address the Veteran's lay statements and December 2019 Board hearing testimony regarding the onset and symptoms associated with the migraine headaches. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 2. Afford the Veteran a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's left hip disability. Any and all studies, tests, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, and private medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: a. Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's left hip disability originated during, or is etiologically related to, active duty service. b. The examiner is also asked to specifically address the Veteran's lay statements and December 2019 Board hearing testimony regarding the onset and symptoms associated with his left hip disability. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. R. Montalvo, 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.