Citation Nr: 21027484 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 17-54 583 DATE: May 5, 2021 REMANDED Entitlement to service connection for headaches, to include as due to Gulf War hazards as due to an undiagnosed illness, and/or due to service-connected posttraumatic stress disorder (PTSD) with alcohol use disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1982 to January 1983, from January 1991 to May 1991, and from January 1964 to July 1964. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). This issue was previously before the Board in March 2019 when the appeal to reopen the claim was denied. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a January 2020 Order granting a Joint Motion for Partial Remand (JMPR), the Court vacated the Board's decision regarding this issue, and remanded the case to the Board for further development and readjudication in compliance with directives specified. The case returned to the Board in July 2020, when it was remanded for further development. That development was completed, and the case has since been returned to the Board for appellate review. Entitlement to service connection for headaches, to include as due to Gulf War hazards as due to an undiagnosed illness, and/or due to service-connected PTSD with alcohol use disorder is remanded. Remand is required for an addendum VA medical opinion. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when the Veteran has provided lay testimony of an in-service injury, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The Veteran underwent a VA examination in January 2021 where the examiner used Disability Benefits Questionnaires (DBQ) for both headaches, and Gulf War General Medical Examination. On the headaches DBQ, the examiner noted no headache diagnosis. On the Gulf War DBQ, the examiner indicated there are no diagnosed illnesses with no etiology, no additional signs and/or symptoms that may represented an undiagnosed illness or medically unexplained chronic multi symptom illness, and that the physical exam was normal. The examiner opined that the headaches are a diagnoseable chronic multi symptom illness with a partially explained etiology. The examiner stated that it is less likely than not that the headaches is related to a specific exposure during service in southwest Asia. The examiner explained that they are unable to confirm a chronic diagnosis with current available records and the exam for the claimed condition of headaches. The examiner opined that the claimed condition is not the result of a specific exposure event in southwest Asia because there is no evidence or chronic treatment for headaches in the claims file. First, the July 2020 Board remand instructed the examiner to address the Veteran's assertions that the headaches are not linked to alcohol abuse. A July 2016 VA medical opinion stated that the evidence showed that the current symptoms may or may not be explained by various etiologies, including alcohol abuse. March 2017 VA treatment records note that the Veteran has a long history of alcohol dependency and chronic headaches, but that the Veteran did not believe that the headaches were related to the alcohol. In the January 2020 JMPR, the Court noted that the Board failed to consider evidence about the relationship between the Veteran's PTSD, alcohol abuse, and headaches in the March 2019 decision. In the July 2020 remand, the Board did consider that evidence in determining that the claim should be reopened, and also used that evidence as a reason to remand the claim for a new VA examination. However, the examiner here failed to address the connection to alcohol in their opinion. Additionally, the July 2020 Board remand noted the July 2016 VA medical opinion's failure to address a June 2015 buddy statement. The statement from a fellow service member described that while in Saudi Arabia they were exposed to heavy dense smoke from oil well fires and burn pits, and that many members of their unit, including the Veteran, became ill, and experienced headaches for several days. While not instructed to address this in the July 2020 Board remand directives, this statement goes to the very heart of the Veteran's claim, and should be addressed. And finally, the Board notes that the January 2021 VA medical opinion stated that they were unable to find a chronic diagnosis, they also stated that the headaches are a diagnoseable chronic multi symptom illness with a partially explained etiology. The Board finds this statement to be contradictory, and also that while stating the headaches have a partially explained etiology, the examiner did not state what that partially explained etiology was. Accordingly, remand is required for an addendum VA medical opinion. By this remand the Board makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the headaches from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the Veteran having sought treatment for his symptoms, and change in the Veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. E) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. F) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition was incurred in, or is otherwise related to, their active service? G) The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the headaches are caused by the service-connected PTSD with alcohol use disorder. H) The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the headaches are aggravated by the service-connected PTSD with alcohol use disorder. I) The examiner must address the following: 1) July 2016 VA medical opinion noting possible connection between headaches and alcohol; 2) the March 2017 VA treatment records noting the Veteran's assertion that the headaches and the alcohol are unrelated; and 3) the June 2015 buddy statement asserting that the Veteran was exposed to heavy dense smoke from oil well fires and burn pits while in Saudi Arabia, and got sick, including with headaches. J) A complete rationale must be provided for all opinions expressed. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rogos 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.