Citation Nr: 20009928
Decision Date: 02/06/20	Archive Date: 02/05/20

DOCKET NO. 18-00 360
DATE: February 6, 2020

REMANDED

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

REASONS FOR REMAND

The Veteran served on active duty from July 1998 to November 2002.

The claim was before the Board in June 2019 when it was remanded for further development, but the August 2019 VA medical opinion obtained is inadequate. Stegall v. West, 11 Vet. App. 268 (1998). The Board remand directed that the opinion provider explicitly address 2017 VA treatment records that identify differing conclusions on the Veteran’s TBI and cognitive issues and discuss whether the TBI symptoms can be distinguished from his mental health conditions. The examiner did not address the differing conclusions specified in the prior Board remand and did not adequately consider and discuss whether the symptoms can be distinguished from his mental health conditions. The claim is remanded for a new opinion. 

The Veteran receives consistent treatment from VA. The most recent VA treatment records associated with the claims file are dated in September 2019. On remand attempts must be made to obtain additional VA treatment records. See 38 C.F.R. § 3.159.

The matters are REMANDED for the following action:

1. Obtain the Veteran’s VA treatment records for the period from September 2019 to the present.

2. Thereafter, schedule a VA examination with an appropriate examiner. The examiner must provide the following opinions:

a) Does the Veteran currently suffer from a TBI or associated residuals that are at least as likely as not related to an in-service injury, event, or disease? In answering this question, the examiner must explicitly address the August 2017 findings of Dr. C.S., VA physiatrist and the September 2017 neuropsychology consultation from Dr. M.W. that document differing conclusions on the Veteran’s TBI and cognitive issues.

b) The examiner is also requested to consider and discuss whether the Veteran’s TBI symptoms can be distinguished from his mental health conditions. In offering the requested opinion, the examiner must address the statements from the Veteran regarding his symptoms, the additional VA treatment records, and whether the Veteran’s TBI symptoms can be distinguished from his mental health conditions. 

 

A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner’s own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made.

 

 

M.E. LARKIN

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Robert J. Burriesci, Counsel

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.