Citation Nr: 19149751
Decision Date: 06/26/19	Archive Date: 06/25/19

DOCKET NO. 10-43 054
DATE:	June 26, 2019

REMANDED

Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded.

Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran had active service from May 2004 to May 2008.  He was awarded a Combat Action Ribbon, among other decorations. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This case was last before the Board in November 2017, when the claims were remanded for additional development.  

1. Entitlement to service connection for residuals of a TBI is remanded.

2. Entitlement to an initial rating in excess of 50 percent for PTSD is remanded.

The November 2017 remand requested an addendum opinion to address whether the Veteran had any TBI residuals.  In January 2018, a VA neuropsychologist opined that the Veteran “has not been diagnosed with any disability due to TBI during any time frame between the concussion in 2005 and the TBI evaluation       in 2016.”  Contrary to the clinician’s finding, a May 27, 2009 TBI evaluation consultation record from a VA psychologist indicated that the Veteran had “mild behavioral slowing with diminished delayed memory. . . results are consistent with multifactorial etiology likely involving mild TBI, PTSD, and some emotional overlay.”  As the January 2018 opinion did not acknowledge the May 27, 2009 VA record, further clarification is required.  Additionally, given the complexity of the issue and the conflicting evidence, the Board finds that the addendum opinion should be authored by a psychiatrist, neurologist, or neuropsychologist.  

Finally, the Board finds that the Veteran’s PTSD claim is inextricably intertwined with the issue of service connection for TBI residuals being remanded and must also be remanded.

The matters are REMANDED for the following actions:

1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities.  After securing any necessary releases, request any relevant records identified.  In addition, obtain updated VA treatment records.  If any requested records are unavailable, the Veteran should be notified of such.

2. After the above is completed to the extent possible, forward the claims file to a psychiatrist, neurologist, or neuropsychologist to obtain an addendum opinion regarding the Veteran's TBI claim.  If an examination is deemed necessary, one should be scheduled.  Following review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has, at any time during the pendency of the appeal, had residuals of a TBI that are related to service.  

The examiner should reconcile his or her findings       with the February 19, 2009 positive TBI screening,       the May 20, 2009 TBI psychiatry note indicating that    the Veteran’s current symptoms appeared to be more associated with PTSD, the May 27, 2009 TBI evaluation indicating “mild behavioral slowing with diminished delayed memory. . . consistent with multifactorial etiology likely involving mild TBI, PTSD, and          some emotional overlay,” the March 19, 2013 VA telepsychiatry record indicating Axis I: history of TBI, the May 2016 VA TBI examination report, and the January 2018 TBI addendum opinion.  

3. If the claims remain denied, issue a supplemental statement of the case.

 

K. A. BANFIELD

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	J. Anderson

The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.