BVA9500848 DOCKET NO. 93-06 149 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for an acquired psychiatric disability, and if so, whether the reopened claim may be granted. 2. Entitlement to an increased evaluation for cephalalgia, "possibly related to sinusitis," currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, his spouse, and mother. ATTORNEY FOR THE BOARD John J. Crowley, Associate Counsel INTRODUCTION The veteran performed honorable active naval service from January 1967 to October 1970. This matter is currently before the Board of Veterans' Appeals (Board) on appeal from recent rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The veteran currently contends that his psychiatric disability was caused by his service connected headache disorder. In September 1977, the RO denied the veteran's claim of service connection for a psychiatric disability on a direct basis. No appeal followed timely notification thereof. Based on a review of the entire evidence of record, the Board concludes that the evidence submitted since this denial is not duplicative or cumulative, and is sufficient, when viewed in the context of the evidence previously of record, to possibly establish a different outcome. Specifically, the veteran was recently diagnosed in an September 1992 VA examination with probable cluster headaches with depression and a sleep disturbance secondary to the probable cluster headaches. For the purposes of establishing whether new and material evidence has been submitted, the credibility of the evidence, but not its weight, is to be presumed. Kates v. Brown, 5 Vet.App. 93 (1993); Justus v. Principi, 3 Vet.App. 510, 513 (1992). On the basis of the foregoing, the Board finds that new and material evidence has been submitted, and the veteran's claim is reopened. REMAND As noted above, the veteran was recently diagnosed with probable cluster headaches with depression and sleep disturbance secondary thereto. However, the veteran has various diagnoses for his psychiatric disability, including a somatization disorder and a dependent personality disorder. Further, while the veteran is currently service connected for cephalalgia, "possibly related to sinusitis," he is not service connected for a cluster headache syndrome. In essence, it is unclear whether the veteran's current cluster headaches can be reasonably dissociated from his complaints of headaches in active service or his current psychiatric disability. In view of the evidence of record, including the veteran's evidentiary assertions that must be presumed to be true for purposes of determining whether his claims are well grounded, the Board finds that his claims are plausible and thus well-grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). King v. Brown, 5 Vet.App. 19 (1993). VA has a duty to assist a veteran in the development of facts pertinent to well-grounded claims. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals has held that the duty to assist includes the duty to obtain thorough contemporaneous VA examinations, including examinations by specialists, when indicated, and the duty to obtain pertinent records. Counts v. Brown, 6 Vet.App. 473 (1994); Hyder v. Derwinski, 1 Vet.App. 221 (1991); Greene v. Derwinski, 1 Vet.App. 121 (1991); Littke v. Derwinski, 1 Vet.App. 90 (1990). Where the record before the Board is inadequate to render a fully informed decision and clarification of the evidence is essential for a proper appellate decision, the Board must remand the case, specifying the action to be undertaken. 38 C.F.R. § 19.9 (1993). In view of the state of the record, we conclude that further development, as specified below, is required. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should request the veteran to identify the names, addresses, and approximate dates of treatment for all health care providers who may possess additional records pertinent to his claims. With any necessary authorization from the veteran, the RO should attempt to obtain copies of those treatment records identified by the veteran which have not been previously secured. 2. After the aforementioned documents have been received, the RO should schedule the veteran for VA psychiatric and neurologic examinations by specialists who have not previously examined the veteran, if available, to determine the nature and extent of the veteran's cephalalgia and any psychiatric disability found to be present. The examiners are specifically requested to diagnose or rule out a diagnosis of cluster headache syndrome, to include whether any somatization disorder found to be present has caused or aggravated this condition. Further, the examiners are also asked to render opinions as to the degree of functional impairment caused solely by the service-connected disability. In addition, it is requested that the examiners review the record and provide an opinion as to the etiology of any psychiatric disability found to be present, to include whether it is at least as likely as not that this disability is related to the veteran's active service or whether it is at least as likely as not that this disability is etiologically related to the veteran's service connected cephalalgia. The claims folder, including the veteran's treatment records, and a copy of this remand should be made available to the examiners for review in conjunction with the examination of the veteran. The veteran should undergo any additional testing deemed necessary by the examiners and such testing results should be made available to the examiners before they make their final determinations. The examiners should fully explain the rationale for their opinions and reconcile any difference in their opinions. All medical reports should be typed. 3. Then, the RO should readjudicate the claim of entitlement to service connection for an acquired psychiatric disability and an increased evaluation in the veteran's service connected cephalalgia on a de novo basis. If any benefit sought on appeal is not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case to the veteran and his representative and provide them an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if otherwise in order. In taking this action, the Board implies no conclusion, either legal or factual, as to any ultimate outcome warranted. No action is required of the veteran until he is notified by the RO. J.F. GOUGH Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).