Citation Nr: 21012769 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 19-17 935 DATE: March 5, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 2010 to April 2011. In an October 2019 decision, the Board denied the Veteran’s claim for an increased initial evaluation for residuals of a TBI. The Veteran appealed this determination to the Court of Appeals for Veterans Claims (the Court). The parties at the Court entered into a Joint Motion for Partial Remand, which the Court granted in October 2020. The issue has returned to the Board for further appellate review. Entitlement to an initial rating in excess of 10 percent for TBI is remanded. Remand is necessary to obtain a new VA examination. When VA undertakes to obtain an opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is considered adequate “where it is based on consideration of the veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one.” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, as per the JMPR, the August 2012 VA examination did not adequately address the Veteran’s reports of vision difficulties and failed to provide an opinion as to whether such symptoms are related to the Veteran’s TBI. As a result, the examiner did not provide the Veteran with an eye questionnaire or appear to consider the Veteran’s complaints of visual impairment. The August 2012 VA examiner also failed to adequately address the Veteran’s reports of short-term memory problems. The examiner opined that the Veteran’s “difficulty with concentration short term memory are most likely from pre-existing attention-deficit hyperactivity disorder (ADHD)”, however the examiner did not explain the inconsistency between the Veteran’s report of short-term memory problems and the examiner’s finding of no complaints of impairment of memory, attention, concentration, or executive functions. Further, the examiner failed to provide an adequate rationale for his opinion that the short-term memory loss is related to ADHD. Therefore, remand is required to obtain a new assessment. The matters are REMANDED for the following action: 1. Obtain VA treatment records from July 2012 onward and associate the records with the claims file. All attempts to secure this evidence must be documented in the claims file. 2. Send the Veteran a letter requesting that he submit, or authorize VA to obtain on his behalf and records of private care that are not already associated with the file. All appropriate steps should be taken to secure identified records. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected TBI. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must address the Veteran’s reports of vision difficulties and complete any accompanying eye questionnaires for visual impairment. The examiner must opine as to whether the Veteran’s vision difficulties are at least as likely as not (50 percent or greater probability) attributable to the Veteran’s TBI. Similarly, the examiner must address the Veteran’s report of short-term memory problems and also opine as to whether the Veteran has short-term memory problems that are at least as likely as not attributable to the Veteran’s TBI. If any symptoms, to include memory problems, are more likely deemed attributable to Attention Deficit Hyperactivity Disorder (ADHD), this should be made clear and explained. The examiner should also estimate the onset date of ADHD. All opinions should be supported by a medical explanation or rationale. (Continued on Next Page) 4. Then, readjudicate the issue on appeal. If the benefit sought remains denied, in whole or in part, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Thompson, 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.