Citation Nr: 21002219 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 17-30 598 DATE: January 13, 2021 REMANDED Entitlement to service connection for traumatic brain injury (TBI) or residuals of TBI is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1967 to June 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision from the Regional Office (RO). The Board denied the claim in February 2019. The Veteran appealed the matter to the U.S. Court of Appeals for Veterans’ Claims (Court). In a December 2019 Joint Motion for Remand (JMR), the parties agreed that a remand was warranted because the Board gave inadequate reasons and bases for the denial of service connection for TBI, to include relying on an inadequate September 2013 VA examination. On remand, the Board was directed by the JMR to obtain a new VA examination and medical opinion to assess TBI. In May 2020, the Board remanded the claim for further evidentiary development and adjudication consistent with the December 2019 JMR directives. The matter has returned to the Board for appellate consideration. Entitlement to service connection for TBI or residuals of TBI is remanded. As noted above, the Board most recently remanded the matter on appeal in May 2020 to obtain an addendum medical opinion. Specifically, the Board instructed the agency of original jurisdiction (AOJ) to schedule the Veteran for an appropriate VA TBI examination. Additionally, the Board instructed the examiner to provide an opinion as to whether it is at least as likely ast not (50 percent or higher degree of probability) that a TBI was incurred or is etiologically related to active service, to include due to head trauma from a MVA and/or due to a June 1968 rocket explosion with multiple fragment wounds to the neck and right leg. See May 2020 Board of Veterans’ Appeals (BVA) Decision. The examiner was also requested to identify any current residuals stemming from any in-service TBI. See May 2020 BVA Decision. Following a review of the evidence of record, the Board notes that the requested VA examination has not taken place. The Board notes that an examination request for TBI was submitted in May 2020. See May 2020 Exam scheduling request. Although it is somewhat unclear, it appears that an examination was scheduled for June 19, 2020 with a provider with a neurology specialty. However, the appointment was not confirmed and no reschedule date or report status was indicated. Further, it appears that a second examination with a provider with a neurology specialty was scheduled for October 2, 2020. Again, it is unclear whether this examination was scheduled in connection with his claim for a TBI or for his claim for neuropathy, which is not part of this appeal. In this regard, a November 2020 supplemental statement of the case (SSOC) provided an adjudicative history which indicated that an examination with a medical opinion was requested on October 8, 2020 and that on October 15, 2020, an examination cancellation was received. Further review of the record reveals that cancellation request dated October 15, 2020 was for an examination for hearing loss and tinnitus and that there was no mention of TBI noted on this form. Additionally, the October 8, 2020 examination request identified in the SSOC documented that only examination requests for hearing loss, tinnitus, and peripheral neuropathy were open at the time. See October 2020 Compensation and pension exam inquiry. As it is not clear whether the Veteran received notice of the scheduled examination, the Board finds that a remand is warranted to obtain new VA examinations for full compliance with the Board’s previous remand instructions. The matter is REMANDED for the following action: Schedule the appropriate VA TBI examination. The relevant documents in the record should be reviewed by the examiner and a detailed history of relevant symptoms should be obtained from the Veteran. All indicated studies should be performed. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The examiner should provide the following opinion: a) Is it at least as likely as not (50 percent or higher degree of probability) that a TBI was incurred in or is etiologically related to active service, to include due to head trauma from a MVA and/or due to a June 1968 rocket explosion with multiple fragment wounds to the neck and right leg? b) If so, are there any current residuals of any in-service TBI? S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hammad Rasul, 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.