Citation Nr: 18150945 Decision Date: 11/19/18 Archive Date: 11/16/18 DOCKET NO. 17-15 938 DATE: November 19, 2018 REMANDED Entitlement to service connection for traumatic brain injury (TBI) with speech, memory, and sleep impairment is remanded. Entitlement to service connection for residuals of craniotomy is remanded. Entitlement to an increased rating for migraines is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 2005 to July 2005, September 2005 to November 2006, and February 2009 to April 2010. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an November 2015 rating decision by the Winston-Salem Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that the RO characterized the claim of service connection for TBI as a request to reopen a claim that was previously denied in March 2014. However, the Board concludes that the claim must be considered without regard to the finality of the March 2014 decision, as new service treatment records have been associated with the Veteran’s claim file. See 38 C.F.R. § 3.156 (c). Specifically, a behavioral health assessment dated August 2008 was associated with the Veteran’s claim file in December 2015. (12/22/2015, STR, p. 7). REASONS FOR REMAND 1. Entitlement to service connection for TBI with speech, memory, and sleep impairment is remanded. The Veteran’s VA medical records indicate that he is receiving “dual care” from the VA and a private provider. The claims file contains very few private medical records, and none reflecting treatment for the issues on appeal; thus, a remand is required to allow VA to obtain authorization and request these records. Moreover, the Veteran has not undergone a VA medical examination for TBI. Generally, a VA examination is necessary when there is competent evidence of a current disability, evidence establishing that an event, injury, or disease occurred in service, and an indication that the disability may be associated with another service connected disability, but insufficient competent medical evidence to decide the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Veteran has presented competent medical evidence of a current diagnosis of TBI. (4/17/2017, CAPRI, p. 103). The Board finds that the record establishes that the Veteran experienced an IED attack while deployed. (12/18/2015, VA 21-0781, Statement in Support of Claim for PTSD, p. 1). As the Veteran indicated that the IED attack caused a head injury, the Board finds that there is an indication that the TBI may be associated with his in-service IED attack. Despite the Board’s conclusions, the record does not contain sufficient evidence to decide the claim. As a result, the Board finds that a VA examination is necessary. 2. Entitlement to service connection for residuals of craniotomy is remanded. The Veteran’s claim of service connection for residuals of craniotomy is inextricably intertwined with the TBI claim. Accordingly, it must be remanded as well. 3. Entitlement to an increased rating for migraines is remanded. The Veteran was granted service connection for migraines with a zero percent rating in a March 2017 decision. The Veteran filed a timely notice of disagreement (NOD) on March 23, 2017, challenging the initial rating for migraines. The RO has not acted on the Veteran’s NOD. Thus, a remand pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999), is necessary. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records for the Veteran’s disabilities from March 2018 to the present. 2. The AOJ should obtain, if possible, records of all private evaluations and treatment the Veteran has received for his disabilities, including surgical records. The Veteran must assist in the matter by identifying his private healthcare providers and by submitting releases for VA to obtain any private records identified. If any private records identified are not obtained pursuant to the AOJ’s request, the Veteran should be so notified and advised that it is ultimately his responsibility to ensure that any available private records are received. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of TBI. The examiner must opine whether it is at least as likely as not related to the Veteran’s active service. In rendering an opinion regarding the Veteran’s TBI, the examiner should: (a.) Consider the Veteran’s lay statements regarding an IED attack; (b.) Consider the Veteran’s post-deployment health reassessment complaint of having been “wounded, injured, assaulted or otherwise physically hurt;” (c.) Discuss the Veteran’s post-deployment health reassessment complaints of headaches, difficulty remembering, and increased irritability; and (d.) The examiner must provide a complete rationale for all opinions expressed. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the cavernous angioma that lead to the Veteran’s craniotomy. The examiner must opine whether it is at least as likely as not related to the Veteran’s active service. In rendering an opinion regarding the cavernous angioma, the examiner should: (a.) Consider if the Veteran’s cavernous angioma is related to TBI. (b.) Discuss the Veteran’s post-deployment health reassessment complaints of headaches, difficulty remembering, and increased irritability; and   (c.) The examiner must provide a complete rationale for all opinions expressed. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Glenn, Law Clerk