Citation Nr: 21064373
Decision Date: 10/20/21	Archive Date: 10/20/21

DOCKET NO. 16-24 879A
DATE: October 20, 2021

REMANDED

Entitlement to a rating in excess of 10 percent for traumatic brain injury (TBI) with mild memory loss, blurry vision and headaches is remanded.

REASONS FOR REMAND

The Veteran had active service from July 1994 to February 2004. This matter is before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

In July 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing.  A transcript of his testimony is of record.

This matter was last before the Board in March 2021, when it was remanded for additional development.  

1. Entitlement to a rating in excess of 10 percent for TBI with mild memory loss, blurry vision and headaches is remanded.

Unfortunately, there has not been substantial compliance with the Board's previous remand directives.  In pertinent part, the March 2021 remand directed that a July 22, 2019 record that was noted to have been scanned into VistA Imaging in an August 2, 2019 VA record be associated with the claims file.  While other records from VistA Imaging were obtained, it does not appear that the July 22, 2019 record was obtained.  Accordingly, another remand is required.  Stegall v. West, 11 Vet. App. 268, 271 (1998).

The evidence indicates there may be outstanding relevant VA treatment records. VA treatment records from January 12, 2021 and January 26, 201 from the Bay Pines VA Medical Center (VAMC) indicate that the Veteran was to return for follow up appointments in April 2021 and October 2021.  VA treatment records after March 1, 2021 have not been associated with the claims file.  Additionally, on his April 22, 2021 VA Form 21-4142 the Veteran reported receiving treatment at the Fayetteville VAMC as recently as September 14, 2014.  VA treatment records   from the Fayetteville VAMC dated after September 11, 2014 have not  been obtained. Moreover, the last record entry from September 11, 2014 indicated      that the Veteran had a follow up appointment scheduled at that facility.  A      remand to obtain the outstanding records is required.

Finally, private treatment records from Charlotte County Employee Health / Carehere (My Health) were received by VA on May 24, 2021.  The records        were not uploaded to the claims file until after the issuance of the June 19, 2021 Supplemental Statement of the Case (SSOC).  As the evidence was received by the agency of original jurisdiction (AOJ) prior to transferring the case to the Board, an SSOC is required.  38 C.F.R. §§ 19.31, 19.37(a) (2020).

The matters are REMANDED for the following actions:

1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities.  After securing any necessary releases, request any relevant records identified.  In addition, obtain updated VA treatment records from      the Bay Pines VAMC dated since March 1, 2021, all treatment records from the Fayetteville VAMC dated since September 11, 2014, as well as July 22, 2019 record that was noted to have been scanned into VistA Imaging in the August 2, 2019 VA record entry.  If any requested records are unavailable, the AOJ should make a formal finding of unavailability and notify the Veteran.

2. If the benefit sought on appeal remain denied, issue a supplemental statement of the case.  

 

 

K. A. BANFIELD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Anderson

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.