Citation Nr: 21028675 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-36 286 DATE: May 11, 2021 REMANDED Entitlement to service connection for headaches, to include as secondary to service-connected neck disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1988 to July 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019 and November 2020, the Board remanded the Veteran's claim for additional development. The case is once again before the Board. During the pendency of the appeal, in a March 2021 rating decision, the RO granted service connection for rotator cuff tendonitis, left shoulder (claimed as left shoulder pain) and assigned an applicable rating and effective date. The Board finds that this grant constitutes a full award of the benefit sought on appeal with respect to this issue. See Grantham v. Brown, 114 F. 3d 156, 1158 (Fed. Cir. 1997). The record contains no indication that the Veteran has appealed the downstream elements of assigned rating or effective date for this disability; thus, this matter is not in appellate status. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). 1. Entitlement to service connection for headaches, to include as secondary to service-connected neck disability, is remanded. Pursuant to a November 2020 Board remand, the examiner rendered a negative nexus opinion because service treatment records "did not show that the veteran while in active duty was treated for headache." He acknowledged that the Veteran presented complaining of headaches when receiving treatment for flu-like symptoms, but he attributed symptoms to the Veteran's acute upper respiratory infection (URI), not a chronic headache condition. The examiner explained that once the Veteran's infection resolved, so did his headaches. Aside from the lack of contemporaneous medical evidence, no further rationale was provided. In addition, the March 2021 VA examiner did not address the Veteran's contentions, and lay statements, of continuous headaches in and since service. In a November 2019 letter, his spouse reported that he "always" complained of headaches when at home for leave. Similarly, in an October 2019 letter, the Veteran's former girlfriend stated that it was not unusual for the Veteran to suffer from headaches for days when they lived together from 1996 to 2001. Because the March 2021 VA examiner did not address lay statements, and the medical opinion is based on lack of contemporaneous medical evidence, the Board finds the VA opinion inadequate to decide the claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA has provided a VA examination or obtained a medical opinion, it is required to provide or obtain one that is adequate for the purpose sought); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006) (VA examiner's opinion inadequate that relied on the absence of contemporaneous medical evidence). The claim is remanded for an addendum medical opinion. Remand is further warranted to obtain a secondary service connection medical opinion. The Board is required to discuss a theory of entitlement raised by the Veteran or by the evidence of record. Robinson v. Peake, 21 Vet. App. 545, 553 (2008). When the Veteran filed his formal service connection claim in August 2014, he included a December 2012 physical therapy evaluation, which suggests that his headaches "may be cervicogenic in nature due to increased tension along [the] sub occipital region." Likewise, a January 2015 Primary Care Note reads, "[history] of cervical [degenerative disc disease] and is symptomatic with [headache] and limited cervical [range-of-motion]." This doctor's note appears to suggest that the Veteran's headaches are a symptom of his service-connected degenerative disc disease of the cervical spine (neck disability). Based on the foregoing, on remand a medical opinion should be obtained on secondary service connection. Finally, as the case is being remanded for additional development, any outstanding VA treatment records should be associated with the claims file. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (per curiam). The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Arrange for an appropriate healthcare provider to review the Veteran's claims file and provide opinions on the nature and etiology of the Veteran's headaches. Provide opinions on the following: a) Whether the Veteran's disability pattern is consistent with (A) an undiagnosed illness, (B) a diagnosable but medically unexplained chronic multi symptom illness, (C) a diagnosable chronic multi symptom illness with a partially explained etiology and pathophysiology, or (D) a disease with a clear and specific diagnosis, etiology, and pathophysiology. i) The term medically unexplained chronic multi symptom illness (MUCMI) means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Examples include, but are not limited to, chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. ii) The examiner should include a discussion of the pathophysiology and etiology of the Veteran's claimed disability and/or reported symptoms. Pathophysiology is defined as the physiology of abnormal states; specifically, the functional changes that accompany a particular syndrome or disease. Consideration of pathophysiology and etiology is a veteran-specific inquiry, as opposed to an inquiry regarding the general knowledge of the medical community. iii) If the Veteran's disability pattern is consistent with diagnosable chronic multi symptom illness with a partially explained etiology and pathophysiology or a disease with a clear and specific diagnosis, etiology, and pathophysiology, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's headache disorder had its clinical onset during service or is due to an event or incident of the Veteran's period of active service, including exposure to environmental hazards. b) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's headache disorder was (A) caused or (B) aggravated beyond its normal progression by his service-connected neck disability. Aggravation means an increase in disabilityany additional impairment of earning capacityof the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinion. However, if there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's statements or recollection are inconsistent with the evidence in this case, medical principles relating to the onset and progress of the disease, the specific findings in the record, and/or your professional judgment. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. Amanda Baker Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Canedy, 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.