Citation Nr: 21065063
Decision Date: 10/23/21	Archive Date: 10/23/21

DOCKET NO. 17-45 648
DATE: October 23, 2021

REMANDED

Service connection for the residuals of a traumatic brain injury (TBI).

REASONS FOR REMAND

Additional development is necessary prior to deciding the claim on appeal.  A February 2020 Board decision denying service connection for the residuals of a TBI was vacated and remanded by the Veterans Claims Court Clerk in a November 2020 Joint Motion for Partial Remand (JMPR).

The Board remanded the appeal in May 2021. In an August 2021 VA opinion, the clinician found that a February 2019 VA CT scan revealed findings consistent with a remote history of TBI, but also that a negative CT did not rule out a history of TBI.  The clinician stated there was no in-service evidence to support an in-service diagnosis of TBI, failing to address the Veteran's contention of an injury during service.  

The August 2021 VA medical opinion is therefore inadequate for failure to address the Veteran's competent recollection of injury during service.  Further, as the clinician stated the available diagnostic evidence was insufficient to rule out a history of TBI, a full examination is warranted.  Therefore, remand for a new opinion and VA examination is necessary.  

The matter is REMANDED for the following actions:

1.  Identify and obtain any outstanding treatment records and associate them with the claims file.

2.  Schedule the Veteran for an examination to determine the etiology of the claimed TBI and any residuals.  The examiner is asked to specifically consider the Veteran's contentions of a head injury in service and address the following:

(a.)  Does the Veteran have a current diagnosis of a TBI, or the residuals of a TBI, or did he have such a diagnosis at any point during the appeal period?

The examiner is asked to specifically consider the following:

	an August 2017 VA clinical note of a medical history of TBI with a cognitive disorder, 

	a September 2017 VA assessment of a reported history of TBI, 

	a February 2019 VA CT scan showing no acute intracranial abnormality, and 

	the Veteran's lay competent reporting of being hit in the head by a flare during service.

(b.)  If symptoms of a TBI or the symptoms consistent with the residuals of a TBI are shown, is it at least as likely as not (a 50 percent or greater probability) related to service?

The examiner should provide full rationales for all opinions rendered. 

 

 

L. HOWELL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Brendan A. Evans, 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.