Citation Nr: 18154488 Decision Date: 11/30/18 Archive Date: 11/29/18 DOCKET NO. 16-51 451 DATE: November 30, 2018 REMANDED Entitlement to a compensable rating for a TBI is remanded. REASONS FOR REMAND Entitlement to a compensable rating for TBI. The Board acknowledges that the Veteran was afforded a VA examination in May 2015. The May 2015 VA neurological examination was requested to determine whether the Veteran had a traumatic brain injury related to head injuries during his active service. The Board notes that Diagnostic Code 8045 states that there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. See 38 C.F.R. § 4.124, Diagnostic Code 8045. However, other than noting that the Veteran had mild memory loss and insomnia, the VA examiner did not undertake a neuropsychological evaluation at that time. Moreover, the Board observes that the Veteran has since complained of headaches and dizziness related to his service-connected traumatic brain injury. As such, the Board finds that the Veteran should be afforded a new VA examination to accurately evaluate the Veteran’s service-connected traumatic brain injury. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that the Veteran was entitled to a new examination after a two-year period between the last VA examination and the Veteran's contention that the pertinent disability had increased in severity). VA’s General Counsel has similarly indicated that when a Veteran asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995) (while the Board is not required to direct a new examination simply because of the passage of time, a new examination is appropriate when the claimant asserts that the disability in question has undergone an increase in severity since the time of the last examination). Furthermore, VA must make all necessary efforts to obtain relevant records in the possession of a Federal agency. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Bell v. Derwinski, 2 Vet. App. 611 (1992). All available VA treatment records for the claims on appeal should be associated with the Veteran’s claims file. The matter is REMANDED for the following action: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his service-connected traumatic brain injury. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. Regardless of the Veteran’s response, any and all VA treatment records should be collected. Any archived records should be retrieved from storage. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. If the records are unavailable, notify the Veteran in accordance with 38 C.F.R. § 3.159. 2. After the foregoing development has been completed to the extent possible, schedule the Veteran for a VA TBI examination conducted by an appropriate physician to determine the current severity and manifestations of his service-connected TBI. All indicated tests and studies, including neuropsychological testing, if warranted, must be accomplished. Based on the examination results, the examiner is asked to identify, and provide an assessment of the current nature and severity of, all service-connected TBI residuals, consistent with the new scheduler criteria for evaluating residuals of TBI under 38 C.F.R. § 4.124a, Diagnostic Code 8045. The examiner is asked to specifically address the degree to which the service-connected TBI disability is manifested by facets of cognitive impairment including to memory, attention, concentration, and executive functions; judgment; social interaction; orientation; motor activity; visual spatial orientation; subjective symptoms; neurobehavioral effects; communication; and consciousness. In making his or her assessment, the examiner should identify all comorbid physical, neurological, or mental disorder(s), and state whether each is shown to be caused by the Veteran’s TBI. If not, then, with respect to each comorbid disorder identified, the examiner should attempt to distinguish any symptoms and impairment attributable to such disability from identified residuals of TBI. If the manifestations cannot clearly be distinguished, then the examiner should clearly so state. The examiner should set forth all examination findings, along with the complete rationale for the conclusions reached, in a report. 3. After completing all indicated development, the RO should readjudicate the Veteran’s claim for an increased disability rating for service-connected traumatic brain injury. If the claim remains denied, the Veteran should be furnished with a supplemental statement of the case and afforded a reasonable opportunity for response GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel