Citation Nr: 20006147
Decision Date: 01/28/20	Archive Date: 01/24/20

DOCKET NO. 16-32 582
DATE: January 28, 2020

REMANDED

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

REASONS FOR REMAND

The Veteran served on active duty from August 1966 to August 1968. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

In November 2019 the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge.  A copy of the transcript is associated with the evidentiary record.  See November 2019 Hearing Transcript. 

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

The Veteran contends that he sustained a traumatic brain injury (TBI) in service in connection with his military occupational specialty as a helicopter crew chief.  The Veteran contends that he was constantly being jarred from one side of the helicopter to the other, and during several hard helicopter landings he sustained numerous blows to the head.  See Hearing Transcript at 10.  The Veteran also testified that shortly after service, in or about 1972, he began seeking VA treatment for headaches.  See November 2019 Hearing Transcript at 4.  The Veteran reported ongoing treatment in the late 1970’s through private treatment provider Kaiser Permanente and continued to receive VA treatment from approximately 1980 to present.  See November 2019 Hearing Transcript at 12. 

The record shows that the Veteran has a current disability of traumatic brain injury and frontal lobe dysfunction secondary to TBI.  See January 2016 CAPRI at 50, see also May 2013 CAPRI at 36. Treatment records show the Veteran sought neurological treatment from VA as early as October 1974.  See May 1981 Medical Treatment Record- Government Facility at 5.  Records also show cognitive difficulties in November 1980 with the Veteran reporting that he felt he had a mental block and frequently had to grope for words.  See September 2003 Medical Treatment Records at 1.  Further, evidence shows ongoing treatment for cognitive and neurological functioning through 2019.  See November 2018 CAPRI; see January 2016 CAPRI; see April 2014 CAPRI.   

Despite the Veteran’s in-service injury and evidence of a current diagnosis of TBI, the record does not contain a VA examination or etiology opinion regarding the Veteran’s TBI, or any residuals thereof.  A VA examination is warranted.   

The matter is REMANDED for the following action:

1. Obtain all outstanding VA treatment records from 1971 to the present, to include any archived records. 

2. After securing any necessary release, obtain any outstanding private treatment records from Kaiser Permanente dated from the mid-1970s to the present.

3. Thereafter, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any traumatic brain injury residuals.  The examiner must opine whether the Veteran’s TBI residuals are at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s contentions that he hit his head multiple times in-service during hard helicopter landings.  

In rendering an opinion, the examiner should consider all evidence of record, including the Veteran’s reports of facial paresthesia as remotely as October 1974 and reports of mental block and paresthesia in 1980. 

All opinions should be supported by adequate rationale.  

 

S. HENEKS

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	A. Wimbish

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.