Citation Nr: A25035307 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240403-428255 DATE: April 16, 2025 ORDER Entitlement to an initial disability rating higher than 70 percent for other specified anxiety disorder with insomnia (hereafter "anxiety disorder") is denied. Entitlement to an effective date prior to October 10, 2023 for service connection for anxiety disorder is denied. Entitlement to service connection for a lumbar spine condition is denied. Entitlement to service connection for a left ankle condition is denied. Entitlement to service connection for a right ankle condition is denied. Entitlement to service connection for a right elbow condition is denied. Entitlement to service connection for a right shoulder condition is denied. Entitlement to service connection for sleep apnea is denied. REMANDED Entitlement to service connection for migraine headaches is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the severity, frequency, and duration of the Veteran's psychiatric symptoms did not more closely approximate total occupational and social impairment. 2. The Veteran's initial claim for service connection for an anxiety disorder was filed on October 10, 2023; this was the first claim for compensation filed by the Veteran, and he did not submit an intent-to-file in the one-year period preceding the filing of the October 10, 2023 claim. 3. The record before the Board does not contain evidence of current lumbar spine, left or right ankle, right elbow, or right shoulder conditions, or a current sleep apnea diagnosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating higher than 70 percent for service-connected anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9410. 2. The criteria for an effective date prior to October 10, 2023 for service connection for anxiety disorder have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2500. 3. The criteria for service connection for a lumbar spine condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 4. The criteria for service connection for a left ankle condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 5. The criteria for service connection for a right ankle condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 6. The criteria for service connection for a right elbow condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 7. The criteria for service connection for a right shoulder condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 8. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Army National Guard with an initial period of active duty training from January 2003 to October 2003 and subsequent active-duty service from November 2004 to February 2006 and from September 2010 to October 2011, to include service in Southwest Asia. The rating decision on appeal was issued in March 2024 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the April 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the March 2024 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 1. Entitlement to an initial disability rating higher than 70 percent for anxiety disorder is denied. The Veteran was awarded service connection for other specified anxiety disorder with insomnia and seeks an initial rating higher than 70 percent. See April 2024 VA Form 10182. The period on review currently before the Board under the AMA is limited to the period considered by the AOJ (i.e., ends at the issuance of the AOJ decision on appeal). The review period and the evidentiary windows are distinct concepts in AMA that are not interchangeable (the review period is the time which VA is assigning a rating for the issue on appeal; the evidentiary window is the time which evidence may be submitted and considered for the issue on appeal). Here, the applicable rating period is from October 10, 2023, the effective date of service connection for this disability, through March 21, 2024, the date of the rating decision on appeal. See 38 C.F.R. § 3.400. The Veteran's service-connected anxiety disorder is currently rated as 70 percent disabling under 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Pursuant to the General Rating Formula, a 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. When determining the appropriate disability evaluation to assign, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board's primary consideration is a Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Veteran has not submitted any argument in support of his contention that his condition warrants an initial disability rating of 100 percent. There are no VA treatment records or private treatment records in the claims file pertaining to the period on appeal. During the period on appeal, the Veteran was offered one VA examination to assess his psychiatric condition. In the November 2023 VA examination, the VA examiner opined that the Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. At the time of the VA examination, the Veteran stated he had been married for approximately five years and had 5 children. He had been working for the same company for the 5 years preceding the examination. The Veteran stated that, since leaving the military, his sleep improved. He reported that he was still experiencing symptoms of anxiety, temper, avoidance, aggravation, and worry. The Veteran denied having a significant legal, behavioral, or substance abuse history. In the November 2023 VA examination, the VA examiner found that the Veteran exhibited the following symptoms related to his anxiety disorder: anxiety, suspiciousness, difficulty in establishing and maintaining effective work and social relationships, difficulties in adapting to stressful circumstances, and impaired impulse control. The November 2023 VA examiner reported that the Veteran seemed anxious but was appropriately dressed, with adequate grooming, good eye contact, clear speech, and goal-directed thought process. The Veteran also denied suicidal ideation as well as psychotic symptoms (hallucinations/delusions). The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. A disability rating of 100 percent is reserved for total occupational and social impairment. Here, the Veteran held consistent employment for several years, had no demonstrated issues with inappropriate behavior and no obvious impairment of thought or communication. Moreover, he was oriented to time and place and denied delusions, hallucinations, and suicidal ideation. Finally, the Veteran did not demonstrate any lapse in recall or memory related to himself, his close relatives, or his occupation. He also did not have total social impairment as he was married and did not report any issues with co-workers. The Board finds the severity, frequency, and duration of the Veteran's symptoms are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. In short, the evidence of record persuasively weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent rating are not met and the appeal must be denied. 2. Entitlement to an effective date prior to October 10, 2023 for service connection for anxiety disorder is denied. Generally, the effective date of an initial claim for service connection will be the later of the date VA received the claim and the date entitlement arose. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. A claimant may indicate the desire to file a claim for benefits by submitting an intent-to-file (ITF) to VA. See 38 C.F.R. § 3.155(b). If, within one year of receiving the ITF, VA receives a complete application for benefits, VA will consider the complete claim to be filed as of the day VA received the ITF. See id. If a complete claim is not filed within 1 year of the receipt of the ITF, VA will not take further action unless a new claim, or a new ITF, is received. See 38 C.F.R. § 3.155(b)(4). Currently, the effective date for the award of service connection for the Veteran's anxiety disorder is October 10, 2023. The Veteran seeks an earlier effective date, but he has provided no argument or any assertion of what date he feels is more appropriate. Regardless, the Board finds that October 10, 2023, is the earliest possible effective date for an award of service connection for the Veteran's anxiety disorder. The Veteran separated from his last period of active-duty service in October 2011 and separated from the Army National Guard in January 2012. The Veteran filed an ITF on February 10, 2020. There was no claim filed within one year of this ITF. Because no claim was filed within the one-year period following the February 2020 ITF, VA may take no further action related to this ITF, to include applying it to the October 2023 claim. See 38 C.F.R. § 3.155(b)(4). The Board notes that the COVID-19 global pandemic was considered a good-cause basis for VA to grant extensions of time limits to submit certain documents or responses. See Policy Letter 20-02, Novel Coronavirus (COVID-19) Claims and Appeals Processing Guidance (PL 20-02). PL 20-02 advised that, effective March 1, 2020, a claimant or a claimant's authorized representative could specifically request an extension of a time limit associated with a required action based on the COVID-19 pandemic including the filing of a claim that would perfect a previously expired communication of ITF. The Board finds no request for extension under PL 20-02 in this case. Therefore, the October 2023 claim does not perfect the February 2020 ITF because it was filed greater than one year later. See 38 C.F.R. § 3.155(b)(4). Here, the Veteran's October 2023 VA Form 21-526EZ was the first time that the Veteran claimed entitlement to service connection for any condition, to include any acquired psychiatric condition such as an anxiety disorder. Being the later of the date VA received the claim and the date entitlement arose, October 10, 2023 is the correct effective date for the Veteran's entitlement to service connection for anxiety disorder. See 38 C.F.R. § 3.400. October 10, 2023, is the earliest possible effective date under law for the award of service connection for anxiety disorder. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Entitlement to an earlier effective date must, therefore, be denied. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of section 1110 as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). For certain chronic diseases, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown in service (or within the presumptive period under 38 C.F.R. § 3.307), to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless they are clearly attributable to intercurrent causes. When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). For veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multi-symptom illness (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome). See 38 C.F.R. § 3.317. A claimant's signs or symptoms need not be shown by medical evidence; however, some objective indications of disability are required. 38 C.F.R. § 3.317 (a). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. See 38 C.F.R. § 3.317(b). When there is an approximate balance of positive and negative evidence regarding any material issue, the Secretary must give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. The benefit of the doubt doctrine applies "if the competing evidence is in 'approximate balance.'" Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc). However, "the benefit of the doubt rule does not apply" when the evidence is not in 'approximate balance' or 'nearly equal'" and "the evidence persuasively favors one side or the other." Lynch at 781-782. 3. Entitlement to service connection for a lumbar spine condition is denied. 4. Entitlement to service connection for a left ankle condition is denied. 5. Entitlement to service connection for a right ankle condition is denied. 6. Entitlement to service connection for a right elbow condition is denied. 7. Entitlement to service connection for a right shoulder condition is denied. 8. Entitlement to service connection for sleep apnea is denied. The Veteran contends that he has musculoskeletal disabilities of the lower back, bilateral ankles, right elbow and shoulder, as well as sleep apnea, that onset in service or are otherwise related to his active-duty deployments with the Army National Guard. See October 2023 VA Form 21-526EZ. Regarding the claims for service connection of the right shoulder, right elbow, and ankles, the Veteran attributes these conditions to in-service injuries and carrying heavy equipment while deployed. See id. Regarding service connection for sleep apnea, the Veteran attributes the onset of this condition to environmental conditions while deployed. See id. Because the Veteran did not appear for examination of any of these claimed disabilities, the Board must decide the issues on appeal based on the other evidence of record. See 38 C.F.R. § 3.655. In the VA Form 10182, the Veteran stated that he missed the appointments due to his work schedule and he requested that they be rescheduled. However, the Board can only remand an appeal for a pre-decisional duty to assist error. Here, his statement for the reason he missed his VA examinations was not of record at the time the decision on appeal was made, so the Board has no basis to remand his claims. The initial threshold question for the Board is whether the evidentiary record reflects that the Veteran has a current disability. The Board concludes that the record does not contain evidence of a current disability for any musculoskeletal condition of the lower back, bilateral ankles, right elbow and shoulder, nor sleep apnea; to include not only at the time the claim was filed but also at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321; 38 C.F.R. § 3.303. The Veteran has not submitted or identified any medical treatment records showing that he has been diagnosed with, or treated for, a diagnosed condition of sleep apnea, nor any lower back, bilateral ankle, right elbow or shoulder condition at any time during the pendency of the claim or recent to the filing of the claim, nor have any such records been received. The Board acknowledges the Veteran's statement in the October 2023 VA Form 21-4138 that he mostly dealt with these conditions on his own; however, the claims file does not indicate that the Veteran has the training or expertise to diagnose these conditions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran was treated for chronic lower back pain and lumbar spine issues during service; however, there is no treatment in the record for this condition since September 2013 (ten years prior to the filing of the present claim) and there is no evidence in the record, during the pendency of the claim, or shortly before its filing, that this condition has persisted to the time of the claim on appeal. The Veteran was treated for acute ankle, right shoulder, and right elbow conditions in service; however, there is no indication that the Veteran has a present disability of his bilateral ankles, right shoulder, or right elbow. There is no evidence in the record of any sleep study or other diagnostic testing for sleep apnea; nor is there record of any, past or present, sleep apnea diagnosis. The Board does note ample evidence of sleep disturbance in service, but the Veteran's insomnia was not a current condition during the appeal period. See November 2023 VA Examination. Therefore, even liberally construing the Veteran's claim for service connection for sleep apnea as one for sleep impairment, generally, there is no current condition for service connection. Resolving all doubt in favor of the Veteran, the Board has considered the filing of the Veteran's October 2023 VA Form 21-526EZ as a statement by the Veteran that he currently experiences lumbar back pain, bilateral ankle pain, right shoulder pain, and right elbow pain. However, even though the Veteran is credible to report such pain, Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007), the record before the Board does not indicate that this pain rises to the level of functional impairment or impairment of earning capacity necessary to be considered a disability for VA compensation purposes. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Again, because the Veteran did not attend his scheduled VA examinations for these conditions, VA is limited to the evidence of record in determining whether a present disability exists for purposes of service connection. See 38 C.F.R. § 3.655. VA does have a duty to assist in developing claims and that duty was satisfied by scheduling the Veteran for VA examinations. Again, the Board cannot remand these claims to reschedule the missed examinations because there was no pre-decisional duty to assist error, as the Veteran did not provide a reason for missing the examinations until after the decision on appeal was made. The Board has considered the chronicity of symptomatology for these musculoskeletal conditions; however, without evidence of a current condition, the presumption applicable to chronic conditions is not for application. See 38 C.F.R. §§ 3.307, 3.309. Finally, there are additional statutory and regulatory provisions potentially applicable to the Veteran, considering he served in Southwest Asia, and it is presumed he participated in a toxic exposure risk activity (TERA). Under the SFC Heath Robinson Honoring Our PACT Act, Pub. L. 117-168, 136 Stat. 1759 ("PACT Act"), examinations and opinions are mandated in certain situations. However, that provision does not apply to the musculoskeletal conditions in this case. See 89 Federal Register 51224 (June 17, 2024); VBA Letter 20-24-06, at page 12 (June 12, 2024). Therefore, there is no basis upon which to order a remand for a medical opinion under the PACT Act for these conditions. The law also provides for compensation for Persian Gulf Veterans who suffer from a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness that became manifest during active duty in the Southwest Asia theater of operations or became manifest to a compensable degree within the prescribed presumptive period and by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Although the Veteran qualifies as a Persian Gulf Veteran, the record does not support the existence of any current, chronic disabilities or current symptoms of "undiagnosed illness" that rise to the level of a disability. Therefore, this provision is inapplicable. In summary, the record does not show that the Veteran had a diagnosis of a lumbar spine condition, ankle condition, right shoulder condition, right elbow condition or sleep apnea at any time during or recent to the filing of the claim. As noted above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. In the absence of proof of a current disability, there can be no valid claim. Brammer, 3 Vet. App. at 225. In view of the foregoing, the Board concludes that the evidence for and against the claim is not in approximate balance, but rather weighs against the claim for entitlement to service connection for these conditions. Because there is not an approximate balance in the weight of the evidence, the doctrine of reasonable doubt is not for application, and the claims for service connection must be denied. The Veteran is reminded that, as stated above, he may file a Supplemental Claim (VA Form 20-0995) with new and relevant evidence of a current medical condition for each of his claimed conditions and VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. 38 C.F.R. § 3.2501. REASONS FOR REMAND Under the AMA, remand is only appropriate if there has been a pre-decisional duty to assist error committed by the AOJ and/or for correction of any other AOJ error in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the claim. 38 C.F.R. § 20.802(a). Here, the Board finds that the AOJ failed to obtain an adequate VA medical opinion. This was a pre-decisional duty to assist error warranting remand. 1. Entitlement to service connection for migraine headaches is remanded. The Veteran claims he has a current headache condition. See October 2023 VA Form 21-526EZ. He is competent to describe experiencing headaches, though not to diagnose himself with a headache condition. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The PACT Act requires that, when a veteran participated in a toxic exposure risk activity (TERA) during their active service and files a claim for service connection for a disability and there is evidence of such disability, VA must obtain a medical opinion addressing the possibility of a nexus between the claimed disability and the TERA, to include providing an opinion regarding the combined effects of all the Veteran's TERA exposures. See 38 U.S.C. § 1168. Here, the Board finds that the Veteran has likely participated in a TERA based on his Gulf War service in the Southwest Asia theater of operations and he has presented some evidence of headaches. Therefore, remand is required to correct the pre-decisional duty to assist error by obtaining an adequate medical opinion which considers the combined effect of the Veteran's TERA exposures. The Veteran's service treatment records indicate he experienced headaches during, and within a presumptive period after, his service in Southwest Asia. Therefore, the PACT Act requires VA to obtain a medical opinion to determine whether the headaches are indicative of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness that cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317. Additionally, in a December 2011 VA treatment record, the VA medical provider determined that the Veteran's headache symptoms were "more related" to his anxiety and sleep disorder than to a mild traumatic brain injury. This opinion is not adequate for service connection purposes because it lacks rationale to support the conclusion and because whether the headache symptoms are "more related" is not a complete opinion as to whether it is as likely as not that the anxiety disorder caused, or merely aggravated, the headache condition. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (conclusory medical opinions are inadequate). Nevertheless, despite being an inadequate opinion, the opinion suggests a theory of secondary service connection and VA has a duty to assist the Veteran in developing his claim under that theory (that the Veteran's headaches were caused or aggravated by his now-service-connected anxiety disorder). Failure to obtain this opinion was a pre-decisional duty to assist error for which remand is required. The matter is REMANDED for the following action: Obtain an addendum medical opinion as to the etiology of the Veteran's claimed headaches. After a complete review of the claims file, an examiner should respond to the following: (a) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's headaches had onset in or are otherwise related to service, to include service in Southwest Asia? (b) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's headaches are due to the synergistic, combined effect of all of the Veteran's toxic exposure risk activities (TERAs)? (c) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that but for the Veteran's service-connected anxiety disorder he would not have headaches? (d) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that but for the Veteran's his service-connected anxiety disorder his headaches would be less severe and result in less functional impairment? (e) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's headaches are a symptom of a chronic disability, to include an undiagnosed illness or MUCMI (medically unexplained chronic multi-symptom illness)? For the purposes of the requested opinions, the examiner should assume the Veteran's statements about his symptoms are credible, unless they are inconsistent with the medical evidence or with medical principles concerning his conditions. The Board emphasizes that this does not constitute a positive credibility determination, as the Board will weigh the evidence should the claim return before the Board. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. In doing so, the examiner may identify any discrepancies, inconsistencies, or contradictions contained in the evidence of record, and may state whether or not the Veteran's lay statements are supported by medical or other evidence. The opinions must be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L.C. Reader, 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.