Citation Nr: 1807804 Decision Date: 02/07/18 Archive Date: 02/20/18 DOCKET NO. 14-24 394 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for residuals of traumatic brain injury (TBI). REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and C.N. ATTORNEY FOR THE BOARD J. Murray, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from June 1977 to June 1980 and from July 1991 to July 2009. This matter comes before the Board of Veterans' Appeals (Board) from an August 2010 rating decision by the Department of Veterans Affairs, Regional Office, located in New Orleans, Louisiana (RO), which denied the benefit sought on appeal. In August 2017, the Veteran and his wife testified before the undersigned during a Board hearing held at the RO. A copy of the hearing transcript has been associated with the claims folder. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran seeks entitlement to service connection for residuals of TBI. He asserts that he suffers from headaches and memory loss as residual of multiple TBI as result of his military service. Based on a review of the claims folder, the Board finds that additional development is needed prior to adjudication of the claim. In particular, the Veteran should be afforded with a new VA examination. A review of the Veteran's service treatment records clearly documents at least one head injury during service related to an explosion from an improvised explosive device (IED) in January 2005, and his service treatment records from that time show he complained of migraine headaches related to injury from IED blast. However, subsequent service treatment records do not document chronic headaches and he denied a history of severe and frequent headaches on March 2009 report of medical history at separation. In the August 2010 rating decision, the RO denied the Veteran's claim because a June 2010 VA examiner concluded that the Veteran's complaints of headaches were not residual of TBI based reported history and clinical evaluation, and his memory loss symptoms had been attributed and compensated by his PTSD disability. The Board notes that the findings in the June 2010 VA examination report are not consistent with findings in the Veteran's VA treatment records just prior to and shortly after that examination. Notably, an initial May 2010 VA TBI evaluation and consultation shows a diagnosis of mild cognitive deficit (memory loss) attributable to TBI. In addition, a month after the VA examination, the Veteran underwent a follow-up July 2010 VA TBI consultation which showed assessment of mild cognitive impairment as residual of TBI, manifested as impaired communication perception, discrimination, and word recognition, as well as short-term memory loss. Also, in support of his claim, the Veteran has submitted an October 2017 completed Headaches Disability Benefits Questionnaire (DBQ) that shows diagnoses of migraine and tension headaches and a notation that the Veteran's headaches are due to cerebral concussion as result of TBI during military service. However, no rational statement was provided in support of this medical conclusion. Based on the foregoing, the Board finds that a new VA examination is needed to identify any current residuals of a TBI and to determine the etiology of such residuals. Accordingly, the case is REMANDED for the following action: 1. Update the claims folder with the Veteran's VA treatment records dated since August 2010. 2. Contact the Veteran and seek his assistance in identifying any outstanding records of pertinent treatment for residuals of TBI. 3. Schedule the Veteran for a VA examination by an appropriate specialist to identify whether the Veteran has any residuals of TBI and the etiology of any such residuals. All indicated tests and studies should be performed. A record of the review of the claims file should be documented in the examination report. Following the examination of the Veteran and a review of the record, the examiner should provide a medical opinion addressing the following: a. Identify whether the Veteran experienced any residuals of a TBI, even if such symptoms have now resolved. b. State whether the Veteran has any psychiatric symptoms that overlap with the residuals of a TBI. If so, identify whether those symptoms can be differentiated from the residuals of a TBI. c. For each residual of a TBI, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the residual was etiologically related to an in-service injury, illness, or event, to include at least one documented head injury that the Veteran sustained in January 2005? In answering the above, the VA examiner should consider and address the Veteran's lay statements regarding the nature and history of his neurological symptoms, as well as the findings from the May and July 2010 VA TBI consultations and October 2017 Headaches DBQ. All examination findings, along with the complete rationale for all opinions expressed, should be discussed in the examination report. 4. Thereafter, readjudicate the claim on appeal. If the benefits sought on appeal remain denied, the Veteran should be provided a supplemental statement of the case. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2016).