Citation Nr: 1739986 Decision Date: 09/18/17 Archive Date: 09/29/17 DOCKET NO. 13-33 156 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for a traumatic brain injury (TBI). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. Cruz, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1968 to November 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in November 2011 of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran contends that he suffers from TBI due to a shrapnel injury he incurred while in-service. In support of this, he has noted that he had a piece of shrapnel removed from his left forehead in July 1987, and he stated on that occasion that this injury occurred during service. In this regard, the service treatment records do not record any shrapnel injury, bur his report of medical history at separation reflected the Veteran reported history indicated that he had a history of head injury. Whether the Veteran has a current head injury that may be diagnosed as a TBI is further complicated by the fact that he experienced post-service head injuries in 1979 and again in 1986. Although a TBI was not specifically noted during the Veteran's active duty service, the Board concludes that his statements regarding an in-service head injury are sufficient such that a VA examination and opinion is necessary. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Board notes that VA policy requires that the initial diagnosis of TBI must be made by a physiatrist, psychiatrist, neurosurgeon, or a neurologist. See The Adjudication Procedures Manual, M21-1, Part III.iv.3.D.2.j (July 24, 2017). Accordingly, the Board finds that the Veteran should be afforded a VA examination by a physiatrist, psychiatrist, neurosurgeon, or a neurologist, in order to determine that nature and etiology of any TBI or residuals stemming from an in-service TBI. The examiner should also take note that the Veteran is service-connected for post-traumatic stress disorder with the associated symptom of impairment of short and long-term memory. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the Veteran's claim file all outstanding VA treatment records for the period from November 2015 to the present. The Veteran should also be provided with the opportunity to submit any private treatment records that may be material to this claim. 2. After any outstanding VA and private treatment records are associated with the claims file, schedule the Veteran for a VA examination by a physiatrist, psychiatrist, neurosurgeon, or a neurologist, to determine the nature and etiology of the claimed TBI or any residuals stemming from an in-service TBI. The claims file is to be reviewed by the examiner in connection with the examination to become familiar with the pertinent medical history. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary the examiner is to provide an opinion regarding: Is it at least as likely as not (probability of at least 50 percent) that the TBI and/or any residuals are etiologically related or had its onset during the Veteran's period of active service? Identify the residuals and any appropriate diagnosis. The examiner must provide a comprehensive rational for each opinion provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. 3. Thereafter, readjudicate the issue on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case which addresses all relevant evidence and afforded the applicable time period in which to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ B.T. KNOPE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2016).