Citation Nr: 21040180 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-62 223 DATE: July 2, 2021 REMANDED Entitlement to service connection for migraines, to include as secondary to service-connected disabilities, is remanded. Introduction The Veteran served honorably on active duty in the United States Air Force during the Peacetime, from April 1985 to November 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 Rating Decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). When this matter came before the Board most recently in February 2020, it was remanded for additional development. As discussed below, the additional development has been conducted and the matter returns to the Board for further appellate review. As will also be discussed below, based upon the evidence of record, the Board has recharacterized the issue on appeal to consider secondary service connection more broadly, specifically, as due to service-connected disabilities generally. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board also observes that, while the matter was pending additional development on remand, the Veteran's private attorney's representation was withdrawn as recognized by VA correspondences to both parties dated July 2020. Currently, the Veteran does not have an appointed representative and, therefore, proceeds pro se. While further delay is regrettable, for the reasons set forth below, the Board finds remand is again required to ensure substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). REASONS FOR REMAND Entitlement to service connection for migraines, to include as secondary to service-connected disabilities, is remanded. In the Veteran's April 2015 claim for entitlement to service connection for migraines, it states her condition is secondary to a service-connected left knee disability. As the Board's February 2020 remand indicated, "no VA examiner has proffered an opinion regarding whether the Veteran's claimed migraine disability is aggravated beyond its natural progression by her service-connected knee disabilities." As a result, the matter was remanded for an addendum opinion. In February 2020, a VA examiner offered such an addendum opinion. For the following reasons, the Board finds the VA examiner's report inadequate for purposes of determining service connection and, thus, there has not been substantial compliance with the prior remand directives. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall, 11 Vet. App. at 271. First, there is no indication the VA examiner considered the pertinent lay or medical evidence of record, as the report is silent as to what, if any, evidence was reviewed. The VA examiner's opinion and rationale are devoid of references to any objective medical evidence of record. Further, the VA examiner failed to report and consider the Veteran's statements regarding when her symptoms first manifested and any progression. See Dalton v. Peake, 21 Vet. App. 23 (2007) (noting that a medical opinion which does not consider the Veteran's reports of symptoms and history, even if recorded in the course of the examination, is inadequate). Moreover, the VA examiner's abbreviated opinion is conclusory in nature, as it fails to offer a reasoned medical analysis in relation to the evidence of record. A bare conclusion, even one reached by a healthcare professional, is not probative without a factual predicate in the record. See Miller v. West, 11 Vet. App. 18, 22 (2007). As such, the Board is unable to conclude that the VA examiner applied valid medical analysis to the significant facts of this particular case. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Further, because the VA examiner's negative nexus opinion does not employ the customary "at least as likely as not" language, it is unclear what evidentiary standard was actually utilized. Finally, the Board observes medical evidence of record suggests an etiological relationship between the Veteran's service-connected lower back condition and her migraines. For example, in June 2015 a VA examiner noted the Veteran "[s]ometimes knows that a headache is coming when gets severe pain traveling from lower back to upper neck." As such, the Board has recharacterized the issue on appeal so as to consider secondary service connection more broadly. Therefore, the Board finds an opinion addressing secondary service connection for migraines as being due to, related to, or otherwise etiologically associated with or aggravated by the Veteran's service-connected lower back disability is also required. Accordingly, the matter is REMANDED for the following action: 1. Schedule the Veteran for an in-person VA examination with a physician who has not previously offered an opinion in this matter and possessing the necessary expertise to fully assess and provide an opinion regarding the nature, severity, and likely etiology of the Veteran's migraines, to include as secondary to service-connected lower back and/or bilateral knee disabilities. **If an in-person examination is not feasible, alternative means of conducting the examination must be employed, such as via telehealth examination with a complete records review. The examiner must obtain a full history from the Veteran. It should be noted the Veteran is competent to attest to factual matters of which she has first-hand knowledge, such as observable symptomology and functional limitations. All pertinent symptomology, including when initially manifested and any progression, must be reported in detail. Any indicated studies must be performed. Based upon a review of all pertinent documents in the Veteran's claims file including medical treatment and examination records, lay statements, and the examination results, the examiner must offer an opinion based upon an accurate medical history with clear conclusions and supporting data as to: 2. Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's migraines are due to, related to, or otherwise etiologically associated with her active duty service. 3. Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's migraines are proximately due to, related to, or otherwise etiologically associated with or aggravated by a service-connected disability including, but not limit to, lower back and/or bilateral knee disabilities. In offering the above opinions, the examiner must consider and discuss as necessary all pertinent lay and medical treatment and examination evidence of record including, but not limited to, the June 2015 VA examination report noting the Veteran "[s]ometimes knows that a headache is coming when gets severe pain traveling from lower back to upper neck." The examiner is advised that, while the lack of medical evidence in STRs and following military discharge are relevant factors, the mere absence of evidence does not equate to unfavorable evidence. The Veteran's lay statements and reports of onset and symptomology must be considered and discussed. A complete and thorough rationale for all opinions expressed, with references to pertinent evidence of record, must be provided. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.