Citation Nr: 20039983 Decision Date: 06/11/20 Archive Date: 06/11/20 DOCKET NO. 17-30 717 DATE: June 11, 2020 REMANDED Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The appellant served on active duty in the U.S. Marine Corps from December 1996 to December 2000. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, denied entitlement to service connection for a TBI. The Board, inter alia, denied entitlement to service connection for a TBI in February 2019. The appellant appealed the Board’s decision to the U.S Court of Appeals for Veterans Claims (Court). In December 2019, the appellant’s representative and the VA General Counsel filed a Joint Motion for Partial Remand. In January 2020, the Court granted the Joint Motion, and remanded the case to the Board for readjudication consistent with the Joint Motion. 1. Entitlement to service connection for a TBI is remanded. In the Joint Motion, it was noted that the Board relied on a September 2015 contracted examination report in which the examiner determined that the appellant did not have a diagnosis of TBI and that his neurobehavioral complaints were more likely due to an underlying psychiatric disability. However, the Board did not consider additional treatment records, including VA treatment notes from the VA Polytrauma/TBI physiatry department classified as TBI follow-ups. Indeed, October 2018 records included notation of a history of TBI. A January 2019 evaluation by a VA Polytrauma/TBI social worker was also not addressed. During an August 2018 polytrauma/TBI physiatry appointment, the appellant endorsed current symptoms of difficulty with memory and headaches, and reported three in-service head injuries. First, he was involved in a blast on deployment in 1998 while training with a police department. He was disoriented, smelled fumes, and was dazed and confused following the explosion. He also saw flash beams and experienced tinnitus. Second, he fell out of a truck at high speed and landed on his head. He remembered that he came to and things looked blurry. He was examined by a corpsman but did not recall going to the emergency department or having any tests done. Finally, he was struck in the head multiple times by another Marine. He experienced confusion, fear, disorientation, and trouble thinking. In view of the foregoing, the Board finds that a new VA examination is necessary. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matter is REMANDED for the following action: Provide the appellant an examination by an appropriate clinician(s) regarding the nature and etiology of any TBI or residuals thereof. The claims file must be made available to, and reviewed by, the clinician(s) rendering the requested opinions. After examining the appellant and reviewing the claims file, the clinician(s) should opine as to whether it is at least as likely as not (50 percent or greater probability) that the appellant currently exhibits a TBI, or residuals thereof, which was incurred in or is otherwise causally related to his active service. Attention is directed to the September 2015 contracted examination report, the August 2018 polytrauma/TBI physiology note which details the appellant’s reports of three in-service head injuries, October 2018 records which note a history of TBI, a January 2019 evaluation report of a VA Polytrauma/TBI social worker, and the buddy statements regarding the appellant’s reported in-service injuries. In providing the requested opinions, the clinician should detail the appellant’s reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant’s reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant’s reported head injuries in service represented the onset or cause of his current disabilities, this should be noted. Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the appellant’s reports generally inconsistent with medical knowledge or implausible? K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Behlen, Associate 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.