Citation Nr: 21022155 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 17-66 575 DATE: April 14, 2021 REMANDED Entitlement to service connection for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from October 1977 to October 1981, and in the U.S. Navy Reserve on active duty from October 2004 to September 2005, with additional Reserve service. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 rating decision. In October 2020 a video conference hearing was held before the undersigned; a transcript is in the record. Entitlement to service connection for TBI The Veteran contends that he experiences residuals of a TBI that he sustained in service in 1981. The Veteran’s service treatment records (STRs) note the Veteran was seen in February 1981 following a reported head trauma about 1.5 months earlier which resulted in pupils of different size. In July 1981 the Veteran was referred from the USS Charles F. Adams for follow up related to head trauma (noted as occurring six to seven months prior.) The Veteran continued to report a history of head injury throughout his periodic “report of medical history” documents with occasional notation that there was no loss of consciousness but some photosensitivity. The Board finds the Veteran’s reports of an in-service head injury to be credible. The Board notes that the Veteran is currently service connected for anisocoria (occurring after the Veteran’s in-service head injury), and separately service connected for muscle contraction headaches (secondary to anisocoria). Whether the Veteran has residuals of a TBI related to his in-service head injury is a medical question. On February 2016 TBI disability benefits questionnaire (DBQ), the examiner stated without any rationale that “in my opinion findings of being struck in the head do not support a claim TBI as a result of being struck in the head.” This opinion does not provide any supporting rationale, and is conclusory. It is therefore inadequate for rating purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Notably, when VA undertakes to provide the Veteran with a medical opinion, it must provide for one that is adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). At the October 2020 video conference hearing, the Veteran testified that he saw stars after he was hit in the head with a stanchion. The Veteran also testified to difficulty following a conversation, recalling recent conversations, difficulty with names of new acquaintances, misspelling words, difficulty maintaining attention/concentration, having trouble sleeping, sensitivity to light, experiencing headaches, and tinnitus. The Board notes that the Veteran is already service connected for headaches and tinnitus and it is recognized that such disabilities began in service. Lastly, in December 2016 the Veteran submitted medical literature from the Brain Injury Association of New York State. See Correspondence received November 29, 2016. Notably, this medical literature has not yet been reviewed by a medical professional. Additionally, an examination has not been conducted that considers the Veteran’s lay statements and testimony in which he describes his current symptoms. See Miller v. Wilkie, No. 16-3046, 2019 U.S. App. Vet. Claims LEXIS 923. Accordingly, a new examination and medical opinion is necessary. The matter is REMANDED for the following action: Arrange for a TBI protocol examination of the Veteran by an appropriate clinician to ascertain whether he has any current disability that is a residual of a head injury from service. The entire record (to include the medical literature submitted by the Veteran in December 2016, as well as the Veteran’s testimony from the October 2020 video conference) must be reviewed by the examiner in conjunction with the examination, and any testing (or imaging) indicated should be completed. On review of the record, examination of the Veteran, and the examiner acknowledging the Veteran’s 1981 head injury the clinician should provide responses to the following: (a.) Does the Veteran have, or at any time during the pendency of this claim has he had, any symptom, pathology, or impairment (and specifically memory loss and cognitive impairment) that are residuals from his in-service head injury sustained in 1981? If so, identify all such residuals found and the clinical findings that support that conclusion. The rationale should include considerations of medical literature submitted by the Veteran, as well as the Veteran’s lay statements and video conference testimony. (b.) If the Veteran is determined to not have any residuals of a TBI in service, but exhibits symptoms that could be considered TBI residuals, explain why here they are not related to a TBI from service, identifying the disability underlying each symptom considered to be more likely. The clinician must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Staskowski, 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.