Citation Nr: 18146821 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 16-32 513 DATE: November 1, 2018 REMANDED ISSUE Entitlement to service connection for a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran had active service from June 1989 to September 1998. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision by the Department of Veterans (VA) Regional Office (RO) in St. Louis, Missouri. As an initial matter, the Board notes that the Veteran’s notice of disagreement (NOD) indicates that he is appealing the RO’s denial of entitlement to service connection for a TBI and the determination that new and material evidence was not received. The RO originally denied the Veteran’s claim in December 2014. The Veteran subsequently submitted additional evidence, and the RO issued another rating decision in July 2015, indicating that new and material evidence had not been received and continuing the denial to service connection for a TBI. The Veteran’s NOD, submitted in August 2015, was timely because it was still within a year of the original rating decision. Therefore, new and material evidence is not at issue because the December 2014 rating decision did not become final. 38 U.S.C. § 7105(b)(1) (2012). Entitlement to service connection for TBI. The Veteran contends that he has a TBI, secondary to his service connected chronic maxillary and frontal sinusitis, status post bilateral sphenoidectomy, polypectomy, and nasal antral windows. STRs indicate that the Veteran underwent surgery related to his sinus problems in in September 1993. Following the surgery, the Veteran complained of a frontal headache and he experienced nausea and vomiting. He was diagnosed with meningitis, and later, encephalitis. In January 1996, the Veteran experienced a spontaneous reopening of the defect in his skull base, which resulted in a cerebrospinal fluid leak and the Veteran falling into a coma for ten days. The record indicates that the Veteran again developed meningitis and encephalitis. In February 1996, he experienced three seizures. He underwent surgical repair of the skull defect in January 1997. Consequently, the Veteran experienced problems with physical functioning, including psychomotor functions, and cognitive functioning, such as memory loss; lack of concentration and attention; and difficulties with planning; organizing, and judgment. The Veteran’s medical evaluations during service indicate a head injury and sinusitis surgery, meningitis, and encephalitis, but STRs throughout the Veteran’s period of active service do not provide a diagnosis of a TBI. An October 2015 post-service treatment record notes that the Veteran had a history of TBI related to a sinus surgery and experienced significant deficits in auditory concentration and memory. An April 2016 VA treatment record notes that the Veteran had an iatrogenic, focal, traumatic brain injury with contusion and laceration of the left frontal lobe during nasal surgeries. This note also indicates that the Veteran’s cognitive and psychiatric difficulties may have some organic basis due to meningitis, encephalitis, comas, and trauma to the orbitofrontal cortex, but the exact causation was unclear. The Board finds that a medical opinion is necessary to clarify whether the Veteran has a diagnosis of TBI and, if a diagnosis exists, determine its etiology. VA’s duty to assist a claimant includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d)(1) (2012); 38 C.F.R. § 3.159(c)(4) (2018). For this reason, remand for an examination is warranted. The matter is REMANDED for the following action: Schedule the Veteran for a VA examination to determine any diagnosis and etiology of his claimed TBI and its residuals. The electronic claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished. All clinical findings must be reported in detail and correlated to a specific diagnosis. (a.) The examiner must provide an opinion, in light of the examination findings and the service and post-service medical evidence of record, addressing whether the Veteran has any diagnosis of TBI or TBI residuals. (b.) If there is a diagnosis of TBI or TBI residuals, provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) caused by or related to his service, specifically addressing the September 1993 sinus surgery. (Continued on the next page)   An explanation for all opinions expressed must be provided. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Hite, Associate Counsel