Citation Nr: 21069984 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 18-36 529 DATE: November 22, 2021 REMANDED Service connection for traumatic brain injury (TBI) is remanded. Entitlement to an initial disability rating in excess of 10 percent for thoracolumbar degenerative disc disease (DDD) with left lower extremity weakness is remanded. REASONS FOR REMAND The Veteran had active service from June 1996 to July 2017. This appeal comes before the Board of Veterans' Appeals (Board) from an August 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). 1. TBI The Veteran contends he has TBI from sustaining a head injury due to multiple falls in service. A remand of this appeal is required to procure outstanding medical records and to obtain an additional medical opinion. VA examination reports dated in December 2016, for both posttraumatic stress disorder (PTSD) and TBI, note that the Veteran does not have a TBI. At an April 2018 VA examination for PTSD, the examiner also indicated that the Veteran does not have TBI. However, other medical evidence of record seems to suggest that the Veteran may have TBI. For instance, service treatment records (STRs) dated in November 2016 show that the Veteran had a history of falling and was referred to TBI specialty. He was provisionally diagnosed with a history of falling. STRs dated in January 2017 note a personal history of TBI, with a severity level of mild. STRs dated in June 2017 show mild to moderate TBI. Private treatment records from N.W.M.F.F., dated in July 2017, note that the Veteran "has diplopia from TBIs." [The Board notes that the Veteran is currently service-connected for diplopia.] On his VA Form 9 (substantive appeal), obtained in June 2018, the Veteran states that, on February 16, 2017, he completed TBI screening and was formally diagnosed with mild to moderate TBI. He further states that the flux in severity is due to ongoing residuals from repeated brain injuries. The Veteran also reports that the provider at the April 2018 VA examination spent nearly the entire appointment time discussing his PTSD history. He indicates that when he mentioned his TBI, the examiner felt that there was no need for further questions. As there is evidence indicating that the Veteran may have a TBI, and to reconcile conflicting medical reports, it is necessary for the Veteran to undergo another VA examination for this disability. In addition, the December 2016 VA examiner noted that the Veteran self-reported that he was seen in the emergency room after falling while exiting an airliner in November 2016. The Veteran further reported that he lost his balance and fell backward, striking his head, and was seen at the St. Thomas emergency room for evaluation. These medical records are not associated with the Veteran's claims file. Thus, on remand, it is necessary for the RO to obtain these records. 2. Thoracolumbar DDD The Veteran was last afforded a VA examination for his back disability in December 2016, almost five years ago. Given the time period since the last examination and the Veteran's statements indicating that his back disability may have worsened due to increased pain and weakness, etc., as stated in his substantive appeal, he should be afforded a new VA examination to assess the current nature and severity of his service-connected thoracolumbar degenerative disc disease with left lower extremity weakness. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The matters are REMANDED for the following action: 1. Associate any updated VA treatment records with the Veteran's claims file and request that he identify any outstanding private treatment records pertaining to the claims on appeal, to include any records from St. Thomas Hospital/Medical Center. 2. Then, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his claimed TBI. The record, to include a copy of this remand, must be made available to and reviewed by the examiner, and the examination report should note such review. Any indicated evaluations, studies, and tests should be conducted. The examiner is asked to: a. Identify/diagnose any TBI the Veteran may have. In answering this question, the examiner is asked to consider and address private treatment records from N.W.M.F.F., dated in July 2017, noting that the Veteran "has diplopia from TBIs;" and STRs dated in June 2017, showing mild to moderate TBI. b. Opine whether any diagnosed TBI is at least as likely as not (50 percent or greater probability) related to the Veteran's active service, to include a 2016 in-service provisional diagnosis of a history of falling. A rationale must be provided for all opinions expressed. 3. Next, schedule the Veteran for an appropriate VA examination to determine the current nature and severity of his service-connected thoracolumbar degenerative disc disease with left lower extremity weakness. The record, to include a copy of this remand, must be made available to and reviewed by the examiner, and the examination report should note such review. Any indicated evaluations, studies, and tests should be conducted. The examiner should report all signs and symptoms necessary for evaluating the Veteran's back disability under the rating criteria. The examiner should also provide the range of motion in degrees. In so doing, the examiner should test the Veteran's range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. The examiner shall inquire as to periods of flare-up and note the frequency and duration of any such flare-ups. Any additional impairment on use or in connection with flare-ups should be described in terms of the degree of additional range of motion loss. The examiner should specifically describe the severity, frequency, and duration of flare-ups; name the precipitating and alleviating factors; and estimate, per the Veteran, to what extent, if any, such flare-ups affect functional impairment. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. All opinions expressed must be accompanied by supporting rationale. A. J. Spector Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Trowers, 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.