Citation Nr: 21041583 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 07-28 524 DATE: July 9, 2021 REMANDED Entitlement to service connection for vision loss is remanded. Entitlement to service connection for a headache disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1967 to July 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office. The claims on appeal have been remanded by the Board in August 2009, March 2011, and March 2019. This case was last before the Board in March 2021, when it was again remanded to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denials and returned the case to the Board. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims and to afford him every possible consideration. 1. Entitlement to service connection for vision loss is remanded. The record reflects that there are outstanding records potentially relevant to these issues. For instance, numerous VA treatment records indicate that non-VA care records had been scanned into VistA Imaging. However, the referenced VistA Imaging records have not been associated with the claims file. Accordingly, on remand all outstanding VistA Imaging records should be associated with the claims file. These records, which are in VA's possession, must be obtained regardless of their relevance as long as they are sufficiently identified. See 38 C.F.R. § 3.159(c); Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). Furthermore, VA treatment records reflect multiple notes referencing a January 2017 eye surgery performed at University of Texas Southwestern Medical Center (UTSW). Additional notes, including an April 2021 record, indicates that the Veteran should continue to monitor eye health at "Dal Eye Oph." It is unclear whether this is a private facility or refers to the Dallas VA Medical Center. At present, those complete private medical records have not been obtained. Because additional records from this provider, if obtained, could bear on the outcome of the Veteran's appeal, specific efforts must be made to procure them. See, e.g., 38 C.F.R. § 3.159(e)(2) (if VA becomes aware of the existence of relevant records before deciding a claim, VA will, among other things, request that the claimant provide a release for the records). 2. Entitlement to service connection for a headache disorder is remanded. Regarding the issue of a headache disorder, the Agency of Original Jurisdiction (AOJ) did not substantially comply with the March 2021 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the March 2021 remand, the Board specifically instructed that, in providing an opinion as to whether it is at least as likely as not that any current headache disability began during active service, the examiner must consider the Veteran's contentions of continued symptomatology following his in-service injury and his in-service complaint of headaches in February 1968. In an April 2021 medical opinion, the examiner opined that the Veteran's headaches were related to the in-service head injury and subsequent complaints of headaches. Thereafter, in a May 2021 addendum, the examiner indicated that upon further review, the Veteran was diagnosed with a non-service-connected brain tumor with history of skull osteoma post-surgery headache disorder. He indicated that the brain tumor was the cause of the headaches, not the 1968 incident. The Board finds that further clarification is needed. In rendering the negative nexus opinion in May 2021, the examiner failed to fully reconcile his contradictory findings as to whether the headache disorder is related to service or take into account the Veteran's assertions of continued symptomatology since the in-service head injury. he matters are REMANDED for the following action: 1. Ask the Veteran to provide releases for relevant private records of treatment from UTSW, and to identify, and provide appropriate releases for, any other private care providers who may possess new or additional evidence pertinent to the issues on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and his representative should be notified. 2. The AOJ should also obtain any outstanding VA treatment records, including all scanned documents contained in the VistA Imaging system and the June 2017 MRI reports. The evidence obtained, if any, should be associated with the record. 3. After the foregoing development has been completed to the extent possible, obtain an addendum opinion from a qualified clinician with respect to the Veteran's headaches. Following a review of the record, the examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any diagnosed headache disorder had its onset in, or is otherwise related to, his military service. In so doing, the examiner must consider and discuss the Veteran's contentions of continued symptomatology following his in-service injury and his in-service complaint of headaches in February 1968. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. A complete rationale for any opinion offered should be provided. 4. If additional VA and/or private treatment records are obtained relevant to the Veteran's eye disorder, an addendum medical opinion should be obtained as it pertains to the etiology of the Veteran's diagnosed eye disabilities. The examiner must provide an opinion regarding whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's current eye disabilities had its onset in, or is otherwise related to, active military service. A complete rationale for any opinion offered should be provided. 5. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue remaining on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Kettler, 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.