Citation Nr: 21015212
Decision Date: 03/16/21	Archive Date: 03/16/21

DOCKET NO. 16-24 879A
DATE: March 16, 2021

REMANDED

Entitlement to a rating in excess of 10 percent for traumatic brain injury (TBI) with mild memory loss, blurry vision and headaches is remanded.

REASONS FOR REMAND

The Veteran had active service from July 1994 to February 2004. 

This matter is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing.  A transcript of his testimony is of record.

This matter was last before the Board in October 2019, when it was remanded for additional development. 

1. Entitlement to a rating in excess of 10 percent for a TBI with mild memory loss, blurry vision and headaches is remanded.

The evidence indicates there may be outstanding relevant VA treatment records.  A VA treatment record from June 29, 2020 indicates that the Veteran was to return for a follow up appointment in September 2020.  VA treatment records subsequent to June 29, 2020 have not been associated with the claims file.  Additionally, VA a treatment record from January 8, 2015 notes that December 12, 2014 brain magnetic resonance imaging (MRI) report had been scanned into VistA Imaging and an August 2, 2019 VA record noted that an unidentified record from July 22, 2019 had been scanned.  It does not appear that the referenced records have been associated with the claims file.  A remand to obtain the outstanding records is required.

There also appear to be outstanding Vet Center treatment records.  VA treatment records from April 11, 2019 indicate that the Veteran received treatment at a local Vet Center and had discussed his TBI symptoms with his provider.  To date, complete Vet Center treatment records have not been obtained.

The record also indicates that there may be outstanding private treatment records.  In October 2013, the Veteran submitted a VA 21-4142 authorizing VA to obtain records from US Health Works.  To date, these records have not been requested or otherwise obtained.  On remand, reasonable efforts should be made to obtain them.

The matters are REMANDED for the following actions:

1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, including his local Vet Center and US Health Works.  After securing any necessary releases, request any relevant records identified.  In addition, obtain updated VA treatment records as well     as the VistA Imaging records referenced in the January   8, 2015 and August 2, 2019 VA record entries.  If any requested records are unavailable, the Veteran should be notified of such.

 

2. If the claim remains denied, issue a supplemental statement of the case.

 

 

K. A. BANFIELD

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	J. Anderson

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.