Citation Nr: 18144463 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 16-35 134A DATE: October 24, 2018 REMANDED Entitlement to service connection for a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1969 to May 1972, with service in Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In this case, the Veteran has referred to new and material evidence to reopen his claim of entitlement to service connection for a TBI. Although the Veteran’s claim was originally denied in May 2014, in January 2015 the Veteran filed additional evidence, to include medical and lay evidence regarding his claim for service connection for a TBI. Therefore, the May 2014 rating decision was not a final decision, and the matter before the Board is not a claim to reopen a previously denied claim for service connection for TBI. Instead, this matter is an appeal of the original claim for entitlement to service connection for a TBI. Entitlement to a TBI is remanded. The Veteran asserts that he experienced head trauma while in service, as he jumped from helicopters and as explosions went off near him. The Veteran’s DD-214 verifies combat in service. The Veteran was afforded a VA examination of his asserted TBI in July 2015 and March 2016. The VA examiners found that the Veteran does not have a diagnosis of TBI. The examiners noted short term memory loss, and reported normal judgment, social interactions routinely appropriate, and orientation to person, time, place, and situation. However, the VA examiners did not note the Veteran’s asserted headaches, mood swings, sensitivity to light and sound, and hallucinations. The Board is reminded that the Veteran is service-connected for PTSD and headaches. Given the evidence of record, the Board remands this matter for an additional VA examination that considers all of the Veteran’s asserts symptoms. The matter is REMANDED for the following action: 1. Obtain any outstanding VA and/or private treatment records. Should such exist, associate them with the Veteran’s electronic claims file. 2. Thereafter, arrange for the Veteran to undergo a VA examination to address the claimed TBI disorder. The relevant information in the claims file must be made available to the examiner for review and the examiner should undertake any indicated studies. The examiner is asked to review the pertinent evidence, including the Veteran’s lay assertions regarding the history of his service and symptomatology. The VA examiner is directed to address the Veteran’s symptomatology, to include short term memory loss, mood swings, hallucinations, sensitivity to light and sound, and headaches. The VA examiner is reminded that the Veteran is service-connected for headaches and PTSD. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) Provide a current diagnosis for any and all TBI disorders found extant. (b) If diagnosed, is it at least as likely as not (i.e., at least equally probable) that the TBI disorder had its onset in or is otherwise causally related to the Veteran’s service, to include any combat (explosions nearby in service) or any jumping off helicopters in service? (c) If no TBI disorder has been found, the examiner is asked to identify the etiology, if any, of the Veteran’s reported short term memory loss, mood swings, hallucinations, sensitivity to light and sound, and headaches. The examiner should view the Veteran as a reliable historian as to his service and his report of his activities in service. See Jandreau, 492 F.3d at 1377. A detailed rationale for the opinions must be provided. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. If the examiner is unable to offer the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Ensure that the examination report is adequate. If it is deficient in any manner, return the report to the examiner as inadequate. Then, after conducting any other development deemed necessary, readjudicate the Veteran’s claim. If the benefit sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC) and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board. Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jamie Tunis, Associate Counsel