Citation Nr: 21065572 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 19-26 860 DATE: October 26, 2021 THE ISSUE Entitlement to service connection for residuals of a traumatic brain injury (TBI), to include a headache disability. REMANDED Entitlement to service connection for residuals of a TBI, to include a headache disability is remanded. REASONS FOR REMAND The Veteran had active-duty service from March 1966 to March 1969. The appeal originates from an August 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran requested a videoconference hearing before a Veterans Law Judge; in August 2021, however, he withdrew his request for a hearing. See 38 C.F.R. § 20.704 (e) (2021). The Board has recharacterized the Veteran's claim for residuals of a TBI as also one for entitlement to a headache disability due to the assertions raised by the Veteran throughout the appeal. See Clemmons v. Shinseki, 23 Vet. App. 1. 6 (2009). This alteration is reflected above Entitlement to service connection for residuals of a TBI, to include a headache disability is remanded. The Veteran contends that he suffers from residuals of a TBI as a result of a hand grenade injury while in service. Medicals records indicate that the Veteran has complained of frequent headaches. The case file contains an August 2018 TBI cognitive screening diagnostic form from Dr. M.C., in which the examiner indicated that there was "probable TBI" and "probable mild dementia." The Veteran was also afforded a VA examination in August 2018. The examiner found that the Veteran did not currently have a diagnosis of a TBI or residuals thereof. The examiner stated, "currently, there is insufficient evidence to diagnose TBI. Per the cognitive screening with [Dr. M.C.] the Veteran is noted to have suspected PTSD and dementia which may account for [his] symptoms, however, without further evaluation, the definitive etiology is unknown." There is no indication the Veteran received any further evaluation referenced by the examiner. Additionally, VA undertook to afford the Veteran a headache examination, however, as VA was unable to contact the Veteran at his current address on file, was unable to schedule such. See August 2019 Statement of the Case. A review of the case file reveals that the Veteran recently relocated to a new address. When VA undertakes to provide an examination or opinion, it must be an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As the August 2018 VA examination appears to have been conducted without the appropriate testing, the Board finds it to be inadequate. Therefore, a new VA examination is warranted to determine the nature and etiology of the Veteran's claimed disability. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Colvin v. Derwinski, 1 Vet. App. 171 (1991) (stating that VA adjudicators are not permitted to substitute their own judgment on a medical matter). Additionally, the Board finds that upon remand, the Veteran should be afforded an opportunity to receive a VA examination for any headache disability present. See Clemmons, 23 Vet. App. 1. 6 (2009); McLendon, 20 Vet. App. 79, 81 (2006). Finally, the Board notes that the most recent VA treatment records date from August 2019. Therefore, upon remand, the RO should attempt to obtain any outstanding VA treatment records. The matters are REMANDED for the following action: 1. Obtain any outstand and relevant VA and/or private treatment records, specifically from August 2019 to the present. Should such exist, associate them with the claims file. 2. Obtain a VA examination from an appropriate medical provider as to the nature and etiology of the Veteran's claimed TBI. After review of the claims file, consideration of the lay statements of record, and physical examination with any needed testing, the examiner should address the following: (a.) List all TBI/head/brain injury residual diagnoses made during the pendency of the period on appeal. (b.) Whether there is any evidence to accept or reject the proposition that the Veteran experienced a head injury in service or experienced chronic residuals of a traumatic brain injury in service. Note, a grenade blast is conceded as it was the basis for the grant of service connection for other conditions. However, the examiner is tasked with explaining whether this instance resulted in a head injury, brain injury, or TBI, and what residuals are associated with this injury. The examiner must provide a rationale for either accepting or rejecting the assertion of said in-service injury to include citing to the presence, or lack thereof, of residual head/brain injury symptomatology such as headaches, cognitive impairment, etc. (c.) The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. 3. Schedule the Veteran with a VA examination with an appropriate VA examiner to address the nature and likely etiology of any headache disability. The examiner must review the claims file, and should note that review in the report. Any studies deemed necessary by the examiner should be accomplished. For any headache disability identified, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that any such headache disability had its onset in service, was aggravated by service, or is otherwise related to any incident of service. Note, a grenade blast is conceded as it was the basis for the grant of service connection for other conditions. Any opinion expressed should be accompanied by a complete rationale. 4. After completing the requested actions, and any other deemed warranted, adjudicate the claims on appeal. If the determination remains unfavorable issue a supplemental statement of the case (SSOC) to the Veteran and his representative which addresses all evidence associated with the claims file since the last statement of the case, and afford the applicable time period to respond. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. E. Geary, 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.