Citation Nr: 18142679 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 15-04 813 DATE: October 17, 2018 REMANDED Entitlement to service connection for residuals of a head injury is remanded. REASONS FOR REMAND The Veteran had active service from November 1972 to March 1976. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge and a transcript of that hearing has been associated with the electronic record. In March 2010, the Veteran filed a claim of entitlement to service connection for residuals of a head injury, and in a March 2010 rating decision, the RO denied entitlement to service connection for that disorder. In July 2010, the Veteran requested a reconsideration of the claim and in October 2010, he requested a reopening of the claim. In the February 2012 rating decision, the RO reopened and denied the claim on a de novo basis. Ordinarily, the Board must initially determine whether the Veteran has presented new and material evidence sufficient to reopen the previously denied claim. See Barnett v. Brown, 8 Vet. App. 1 (1995), aff’d, 83 F.3d 1380 (Fed. Cir. 1996). The Veteran, however, submitted service treatment records that are related to the in-service head injury as part of his claim to reopen. Therefore, VA must reconsider the claim on a de novo basis. 38 C.F.R. § 3.156(c) (2017). VA treatment records reflect that a treating neurologist has noted that the Veteran has residual left-sided weakness from a 1973 traumatic brain injury. In an November 2014 medical opinion, a VA doctor stated that most of the Veteran’s residuals damage was done in 1994 after a post-service head injury. Given the conflicting medical evidence and the fact that the VA medical opinion did not attribute all residuals to a post-service injury, another VA examination is necessary. In October 2014, the Veteran reported VA treatment in St. Louis from 1976 to the present. The RO should obtain all VA treatment records not currently associated with the electronic claims file. An April 2010 VA treatment record reveals that the Veteran was recently treated at Barnes Hospital. The RO should obtain all records from that facility. VA treatment records shows that in March 2001 the Veteran was planning to appeal a denial of a claim for Social Security disability benefits. Records from the Social Security Administration show a history of a denied claim. A May 2001 VA treatment record reflects that the Veteran had been receiving disability benefits from the State of Missouri for residuals of a head injury but that the benefits had expired a few years ago. The RO should obtain all records from Social Security Administration and any available records pertaining to a claim for disability benefits paid by the State of Missouri. The matter is REMANDED for the following action: 1. Ask the Veteran to identify all treatment for his residuals of a head injury and obtain any identified records. Obtain the Veteran’s VA treatment records from VA St. Louis Health Care System for the period from January 1976 to February 2014 and from April 2015 to the present. Ask the Veteran to complete a VA Form 21-4142 for Barnes Hospital. Make two requests for the authorized records from Barnes Hospital, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s federal records from the Social Security Administration regarding his claim for Social Security disability benefits. Document all requests for information as well as all responses in the claims file. 3. Obtain the Veteran’s records from the State of Missouri regarding any claim for state disability benefits. Document all requests for information as well as all responses in the claims file. 4. After the development in 1 through 3 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any residuals of a head injury. The examiner must opine whether it is at least as likely as not that any current disability, including hemiparesis and any current headache disorder, is related to an in-service injury, event, or disease, including the in-service head injury in May 1973 and the reporting of frequent headaches on the November 1975 separation examination. 5. Thereafter, readjudicate the claim on appeal. If the benefit sought in connection with the claim remains denied, the Veteran and his representative should be provided with an appropriate Supplemental Statement of the Case (SSOC) and given the opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Cherry, Counsel