Citation Nr: 22015231 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 19-24 928 DATE: March 16, 2022 REMANDED Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an initial compensable rating for right ear hearing loss is remanded. Entitlement to service connection for chronic fatigue syndrome (CFS) is remanded. Entitlement to service connection for chronic headaches is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Air Force Reserve from June 2009 to December 2009 and December 2010 to June 2011. The Veteran testified at a November 2021 Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. 1. Entitlement to an initial rating in excess of 30 percent for PTSD is remanded. 2. Entitlement to an initial compensable rating for right ear hearing loss is remanded. A remand is required to obtain a VA examination. The Veteran last underwent VA examinations for PTSD and hearing loss in February 2018. However, since that time the Veteran stated in the November 2021 Board hearing that her PTSD and right ear hearing loss have worsened. Board Hearting Transcript (T.) at 9-10, 11. As it has been over four years since the Veteran had been provided with a VA examination concerning her claims for increased rating and there is an assertion of worsening symptomatology, a remand is warranted to ensure that the record contains evidence of the current severity of the Veteran's service-connection PTSD and right ear hearing loss. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Green v. Derwinski, 1 Vet. App. 121 (1991); Caffrey v. Brown, 6 Vet. App. 377 (1994). 3. Entitlement to service connection for CFS is remanded. Remand is necessary to obtain an addendum VA opinion, or a new VA examination if necessary. When VA undertakes to obtain an opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is considered adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, in a March 2018 statement, the Veteran stated that during her deployments she was subjected to a variety of environments and toxins. She stated that she was exposed to burn pits and is in the burn pit registry. She stated that she complained of fatigue and reported the symptoms when she returned from deployments. At the November 2021 Board hearing, the Veteran testified that immediately after her deployment she experienced a change in her sleep and fatigue. T. at 8. The Veteran stated that she was exposed to burn pits during service. T. at 12. The Veteran testified that she registered for the burn pit registry. T. at 7. The Veteran stated she continues to experience fatigue. Id. She stated she cannot stay awake throughout the day. Id. She stated she falls asleep during conversations with others. Id. She stated she is unable to have a full night's sleep. T. at 16. The Veteran underwent a February 2017 VA examination. However, the Board finds that the VA examiner did not address all of the Veteran's symptoms or diagnosis of sleep phase syndrome and sleep maintenance insomnia. Therefore, the Board finds that the examination and rationale do not offer sufficient detail for the Board to make an informed decision regarding a nexus between the Veteran's symptoms of fatigue (or other sleep disorder) and service, specifically complaints of onset during service and symptoms since separation from service. Therefore, remand is required to obtain a new VA opinion. 4. Entitlement to service connection for chronic headaches is remanded. Remand is required to obtain a VA examination. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the United States Court of Appeals for Veterans Claims indicated that there was a four-part test to determine whether an examination was necessary under 38 C.F.R. § 3.159(c)(4). Id. at 81. Under this test, VA will provide a medical examination or obtain a medical opinion where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence to make a decision on the claim. Id.; see also 38 C.F.R. § 3.159(c)(4). Here, in a March 2018 statement, the Veteran stated that she has experienced chronic headaches for years and averages approximately two to three headaches per week. She stated that she complained of headaches when she returned from both deployments. At the November 2021 Board hearing, the Veteran testified that she experienced headaches during active service and continued to experience headaches after separation from service. T. at 5, 6, 12. Therefore, the criteria for McLendon have been met. And as a result, the Board cannot make a fully informed decision on the issue of entitlement to service connection for a chronic headache disorder because a VA examination has not been performed and no VA examiner has opined whether the Veteran's chronic headache disorder was caused by service. Therefore, a VA examination is necessary. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to her service-connected PTSD. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected right ear hearing loss. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to her service-connected right ear hearing loss. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any disability manifested by fatigue, to include CFS, sleep phase syndrome, and sleep maintenance insomnia, found to be present. For each such disorder diagnosed, the examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including in-service complaints of fatigue. The examiner must consider the Veteran's lay statements and contentions in the context of any negative opinion. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of a chronic headache disorder. The examiner must opine as to whether the disability is at least as likely as not related to an in-service injury, event, or disease, including in-service complaints of headaches. The examiner must consider the Veteran's lay statements and contentions in the context of any negative opinion. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thompson, 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.