Citation Nr: 22019765 Decision Date: 04/03/22 Archive Date: 04/03/22 DOCKET NO. 17-57 352 DATE: April 3, 2022 REMANDED Entitlement to service connection for a headache disability, to include as secondary to a service-connected thoracic spine, right knee, and tinnitus disability is remanded. Entitlement to service connection for an acquired psychiatric disability, to include as secondary to a service-connected thoracic spine, right knee, and tinnitus disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from May 1977 to May 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office. These matters were previously before the Board in April 2020. The Board finds new and material evidence to reopen the Veteran's acquired psychiatric claim but remanded both claims to obtain outstanding social security administration (SSA) records. These matters are again before the Board for adjudication. As an initial matter, the Board notes that following the April 2020 remand, the Veteran's SSA records and additional VA treatment records were associated with the Veteran's claims file. However, no supplemental statement of the case has been issued. A review of a January 2021 Appellate Brief indicate that the Veteran's attorney submitted additional evidence and indicated that he waived consideration of the attached evidence by the Regional Office. However, it is unclear to the Board whether the Veteran's attorney also waived the Regional Office's review of the Veteran's SSA records and VA treatment records. The Board acknowledge that a waiver of regional office review of any additional VA treatment records or government records is required when additional VA treatment records or government records have been associated with the claims file after an issuance of a statement of case or supplemental statement of case. However, the Board finds that a waiver is not warranted at this juncture as the Board finds that a remand of both issues is warranted. 1. Headache disability 2. Acquired psychiatric disability Upon review of the evidence, additional remand is warranted before the Board can adjudicate the merits of the claims. In a September 2018 VA examination for his headache and acquired psychiatric disability, a private examiner indicated that his claimed disabilities were caused or aggravated by his service-connected thoracic spine, right knee, and tinnitus disability. The private examiners further referenced several research articles which indicates that a relationship exist between the Veteran's claimed disabilities and his service-connected disabilities. The Board finds that these evidence raises a theory that has not been previously addressed. Additionally, the Board finds that the Veteran has not been provided with a VA examination for his headache disability. The Board acknowledge that there are several disability benefits questionnaires labeled as "VA Examinations," but these disability benefits questionnaires were completed by private examiners and submitted by the Veteran and his attorney. As the Veteran has not been provided with a VA examination, the Board finds that a VA examination is warranted to determine the nature and etiology of the Veteran's headache disability. Regarding the Veteran's acquired psychiatric disability, the Board notes he was last provided with a VA examination for his acquired psychiatric disability in April 1988. In light of the new evidence and theory asserted by the Veteran, the Board finds a new VA examination is warranted to determine the nature and etiology of the Veteran's acquired psychiatric disability. Similarly, as discussed above, while there are recent "VA examinations" associated with his claims file, these are private disability benefit questionnaires. Based on the foregoing reasons, the Board finds a remand is warranted to obtain VA examinations to determine the etiology of his headache and acquired psychiatric disability. These matters are REMANDED for the following action: 1. Obtain any outstanding VA or private treatment records related to the Veteran's headache and acquired psychiatric disability and associate them with the claims file. 2. Schedule the Veteran for an examination with an appropriate examiner for his headache and acquired psychiatric disability. The claims file, including a copy of this remand, should be made available to the examiner, who should review it in conjunction with the prior examination and should note that review in the report. The examiner is requested to provide an opinion for the following questions: (a) Is the Veteran's headache disability at least as likely as not (50 percent probability or greater) etiologically related to an in-service event, injury, or disease? (b) Is the Veteran's headache disability at least as likely as not (50 percent probability or greater) (1) proximately caused or (2) aggravated beyond its natural progression by his service-connected thoracic spine, right knee, or tinnitus disability? (c) Is the Veteran's acquired psychiatric disability at least as likely as not (50 percent probability or greater) etiologically related to an in-service event, injury, or disease? (d) Is the Veteran's acquired psychiatric disability at least as likely as not (50 percent probability or greater) (1) proximately caused or (2) aggravated beyond its natural progression by his service-connected thoracic spine, right knee, or tinnitus disability? In addressing secondary service connection for the Veteran's headache and acquired psychiatric disability, the examiner is requested to address the research articles cited by the private examiners in a September 17, 2018 file labeled as "VA Examination." A complete and detailed rationale for these opinions should be provided for every opinion requested by the examiner. (Continued on the next page) 3. After, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran with a supplemental statement of the case (SSOC) and provide him with an appropriate opportunity to respond. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Xiong, 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.