Citation Nr: 20072826 Decision Date: 11/12/20 Archive Date: 11/12/20 DOCKET NO. 15-38 501 DATE: November 12, 2020 REMANDED Entitlement to service connection for a traumatic brain injury (TBI) with memory loss is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2010 to September 2013. This matter comes before the Board of Veterans’ Appeals (Board) from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing with the undersigned in November 2018. This issue was previously remanded by the Board in May 2019 and has since been returned for further adjudication. Although the Board regrets additional delay, remand is necessary to obtain an addendum opinion based on the factual record. The Veteran underwent a VA examination in November 2019 to determine if he had a diagnosis of TBI, and if so, if it was related to his military service. The examiner stated that the Veteran’s report of head injury with loss of consciousness, by definition, and only by subjective and not documented corroborating records, matches criteria for TBI. However, for VA rating purposes, in non-active-combat situations, a current diagnosis of historical TBI cannot be made. Although the condition subjectively developed during service, and subsequent symptoms were subjectively present during service, the claimed condition was never diagnosed in service. Given the above, any medical provider trained in TBI and VA rating protocols would more likely than not reasonably confirm no diagnosis of TBI. The opinion was based in part on no corroboration of a loss of consciousness during service. The Veteran asserts he fell in the shower and hit his head during service. A service treatment record from October 2012 includes a notation from an emergency department physician that the Veteran experienced a fall with headache and unknown loss of consciousness. A head CT was performed, and the history provided at that time indicated “Fall, loss of consciousness, dizziness, headache, alcohol use.” During mental health evaluation in March 2013, the Veteran reported experiencing multiple falls down stairs and that he fell in the shower. He reported having experienced a loss of consciousness for over an hour after which he was transported to the emergency room in 2012. During his March 2013 separation examination, the Veteran reported having a previous head injury as well as a period of unconsciousness or concussion. He noted falling in the bathtub and ending up in the emergency room, as well as having a lot of falls down stairs. The Board is making a favorable factual finding that the Veteran did experience a loss of consciousness during service in October 2012 when he fell in the shower. A new opinion should be obtained with this in mind. Finally, the May 2019 Board remand instruction regarding verification of whether the October 2014 and September 2015 VA examiners were qualified to diagnose the Veteran with a TBI was not completed. See Stegall v. West, 11 Vet. App. 268 (1998); see also VA Adjudication Manual M21-1, III.iv.3.D.2.j. This matter is REMANDED for the following action: 1. Add to the claims file verification as to whether the physician who performed the October 2014 VA examination and the physician who offered the medical opinion in September 2015 were physiatrists, psychiatrists, neurosurgeons, or neurologists. 2. Schedule the Veteran for a VA examination with a physiatrist, psychiatrist, neurosurgeon, or neurologist to determine whether it is at least as likely as not (50 percent probability or greater) that he has current residuals of an in-service TBI. The examiner is asked to accept as fact that the Veteran experienced a loss of consciousness after falling in the shower in October 2012. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. The examiner is asked to review the October 2014 VA TBI examination report, March 2015 VA TBI/ Polytrauma Consultation Note, September 2015 VA medical opinion, and November 2019 VA medical opinion. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Hofmeister, Attorney Advisor 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.