Citation Nr: 21075397 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 16-52 029 DATE: December 20, 2021 REMANDED Entitlement to service connection for residuals of a head injury, to include residuals of a traumatic brain injury (TBI), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1964 to January 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified at a video-conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. Most recently, the Board remanded this matter for further development in July 2021. Unfortunately, the Veteran's claim must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim, so he is afforded every possible consideration. Entitlement to service connection for residuals of a head injury, to include residuals of a TBI, is remanded. The Board previously remanded this matter to obtain an adequate medical opinion addressing the etiology of the Veteran's claimed residuals of his in-service head injuries. Specifically, the Board found previous opinions inadequate as they did not explain why a diagnosis of a TBI was necessary for any residuals of a head injury to be connected to the Veteran's in-service head injuries. An August 2021 medical opinion provided a negative opinion, rationalizing that the Veteran's service treatment records (STRs) were silent for a head injury. An October 2021 addendum opinion also provided a negative nexus opinion, stating there was insufficient evidence that the Veteran sustained an in-service TBI. The Board finds the August 2021 and October 2021 addendum opinions inadequate, as neither were responsive to the directives of the prior Board remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance, rather than absolute compliance, with remand orders). Additionally, the August 2021 opinion only addressed the Veteran's in-service October 1964 trampoline injury and the October 2021 opinion only addressed the April 1964 automobile accident. The Board notes that February 1965 STRs reflect the Veteran was seen for a scalp laceration. Furthermore, the Veteran has stated that he experienced an additional in-service head injury when he was thrown from a truck. See September 2015 Statement in Support of a Claim; December 2015 Statement in Support of a Claim; August 2019 Hearing Transcript. This incident is also corroborated by a fellow servicemember who was also in the truck at the time of the accident. See Undated Buddy Statement, received by VA March 3, 2016. Accordingly, the Board finds the August 2021 and October 2021 addendum opinions inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."); Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner relied on the absence of evidence in the Veteran's service medical records to provide a negative opinion). As such, the Board finds that an addendum medical opinion is warranted to determine the nature and etiology of any residuals the Veteran currently has as a result of his in-service head injuries. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records, dated from June 2021, forward. 2. Thereafter, obtain an addendum medical opinion from an appropriate clinician. If the clinician determines that an additional examination (or telehealth interview) of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled; however, the Veteran should not be required to report for another examination (or telehealth interview) as a matter of course, if it is not found to be necessary. The examiner must review the claims folder, to include a copy of this REMAND. The examiner should provide the following opinions: (a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran has any current residuals related to his in-service head injuries. (b) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's headaches and/or loss of balance are related to his in-service head injuries. In reaching these opinions, the examiner should consider and address: The STR showing that the Veteran was seen in the emergency room following an automobile accident on April 6, 1964, and the corresponding skull X-ray. The STR reflecting the Veteran was seen in the emergency room on October 31, 1964, after suffering a head injury while jumping on a trampoline. The STR of November 6, 1964, noting the Veteran continued to experience headaches. The statements of the Veteran and his fellow servicemember describing that the Veteran was injured in an in-service truck accident in which the Veteran was thrown from a truck, landed on his back, and reportedly suffered from headaches and back pain a few days later. Both the Veteran and his fellow servicemember stated they did not report the accident. STRs of February 1965 that show he was seen for a dressing change and treatment of his back and scalp laceration. (Continued on the next page) The examiner must provide a complete rationale for all opinions expressed. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. M. Stedman, 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.