Citation Nr: 21063166 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-28 065 DATE: October 13, 2021 REMANDED Entitlement to service connection for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served in active-duty service with the Navy from December 1985 to August 2006. This matter is on appeal from a June 2016 rating decision. The Board finds that remand is warranted for additional development. The Veteran claims a TBI related to his active-duty service. In a July 2016 notice of disagreement, the Veteran stated that he has been diagnosed and received treatment for TBI. In a May 2017 form 9 statement, the Veteran stated that he has suffered from symptoms of short-term memory issues and dizziness relating to being hit in the head with a shoring kit in service. A January 2016 VA medical center (VAMC) record notes the Veteran with a "mild neurocognitive disorder due to TBI" as well as the Veteran's complaints for concentration and memory but does not provide any further detail or clarification regarding this documentation. The Veteran has submitted a medical record which lists active problems to include mild neurocognitive disorder "due to TBI" dated from November 2013. Review of the record does not show that the record of this diagnosis or treatment have been associated with the record. The Veteran also submitted a November 2012 Social Security Administration (SSA) decision The Board also notes that review of the record does not show the Veteran has been afforded a VA examination regarding the nature and etiology of his claimed TBI. As such, the Board finds that remand is warranted for examination and to obtain outstanding records to associate with the claims record. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. Request that the Veteran provide the names and addresses of any and all healthcare providers who provided treatment for the Veteran's claimed TBI to include records relating to the November 2013 notation of TBI and treatment. After acquiring this information and obtaining any necessary authorization, obtain and associate any pertinent records with the claims folder. 3. Confirm with the Social Security Administration (SSA) whether the Veteran is receiving SSA disability benefits, obtain the Veteran's SSA records pertinent to the Veteran's claims for a TBI, and associate them with the Veteran's claims file. All records/responses received must be associated with the electronic claims file. 4. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A (b)(2) and 38 C.F.R. § 3.159(e). 5. Schedule a VA examination with an appropriate provider to determine the nature and etiology of the Veteran's TBI disability. The complete record, to include a copy of this REMAND, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. The examiner should respond to the following: (a.) Identify any current TBI disability or related symptoms and residuals, to include headaches, memory issues, and/or dizziness. (b.) If the Veteran has a TBI disability, is it at least as likely as not (a 50 percent or greater probability) that any neurological disorder had its onset during active service or is etiologically related to the Veteran's active-duty service? (c.) The examiner is advised that the Veteran is competent to report in-service events and treatment, and the Veteran's symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. (d.) The examiner is asked to address the statements made by the Veteran in the July 2016 notice of disagreement (NOD) and May 2017 form 9. The examiner should also address the complaints of dizziness and headaches in January 1999; dizziness in February 2005; and March 2006 report of dizziness as reported in the Veteran's service treatment records (STRs). (e.) If the examiner cannot provide the above opinions, the examiner is advised that he/she must explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies). (f.) If the examiner cannot provide an answer because further information is needed to assist in making the determination, all reasonable steps to obtain the missing information should be exhausted before concluding that the answer cannot be provided. (g.) The opinions should include a discussion of any pertinent studies or medical literature, as well as pertinent evidence on file. (h.) If the VA examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. A clearly stated rationale for any opinion offered should be provided. 6. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Yang, 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.