Citation Nr: 21022749 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 14-44 415 DATE: April 19, 2021 ORDER Entitlement to service connection for traumatic brain injury (TBI) is denied. REMANDED Entitlement to service connection for left arm/shoulder condition (claimed as pain-fatigue) is remanded. Entitlement to service connection for left leg/hip condition is remanded. Entitlement to service connection for optic neuritis is remanded. FINDING OF FACT The Veteran does not have a current diagnosis of traumatic brain injury. CONCLUSION OF LAW The criteria for service connection for a traumatic brain injury (TBI) have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1968 to August 1970. 1. Entitlement to service connection for TBI The Veteran contends that he suffered a train brain injury during service that persists to the present. After a thorough review of the evidence, the Board finds that entitlement to service connection for traumatic brain injury (TBI) is not warranted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of TBI and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The August 2019 VA examiner evaluated the Veteran and determined that he did not experience “headaches or other symptoms typical of TBI nor did he develop hip pain until a couple years ago.” The VA examiner acknowledged that the Veteran had taken a fall from about 16 feet during service and the Veteran is unsure if he had loss of consciousness at the time, which may have been a couple seconds, if at all. The examiner stated that there was no current diagnosis of traumatic brain injury. The Veteran’s medical treatment records do not contain indication that he has a current diagnosis of TBI. While the Veteran believes he has a current diagnosis of TBI, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specific medical knowledge and evaluation of symptoms and medical history. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. In summary, the preponderance of the evidence is against finding a current diagnosis for TBI. There is no reasonable doubt to be resolved in the Veteran’s favor, and service connection cannot be granted under any reasonably raised theory. 38 C.F.R. §§ 3.102, 3.303. REASONS FOR REMAND 1. Entitlement to service connection for left arm condition (claimed as pain-fatigue) is remanded. The Veteran had a VA examination for arm/shoulder conditions in August 2019. The examiner diagnosed left shoulder impingement syndrome and left AC joint arthritis, but only opined on the right shoulder’s connection to service. The RO granted entitlement to service connection for cervical spine degenerative joint disease in a May 2020 rating decision. The RO should determine if the grant of entitlement to service connection for left arm upper extremity radiculopathy meets the Veteran’s claim for service connection for a left arm condition. The RO should obtain an addendum opinion to determine if there are any remaining left arm/shoulder conditions that may be related to service or secondary to the Veteran’s service-connected cervical spine disability. 2. Entitlement to service connection for left leg/hip condition is remanded. The Veteran had a VA examination for hip/thigh conditions in August 2019. The RO issued a supplemental statement of the case in May 2020 denying entitlement to service connection, partially because the Veteran was not granted service connection for lumbar spine disability at the time. In October 2020, the RO granted entitlement to service connection for lumbar spine disability and left lower extremity radiculopathy. The RO should obtain an addendum opinion to determine if there are any remaining left leg or hip conditions that might be related to service or secondary to the Veteran’s service-connected disabilities such as lumbar spine arthritis, or determine if the Veteran is satisfied with the current award given that his claim was for any left leg condition. 3. Entitlement to service connection for optic neuritis is remanded. The Veteran had a VA eye examination in August 2019. At the examination, the provider stated that there was no macular degeneration, contrary to the summary in the May 2020 Supplemental Statement of the Case which stated that the Veteran’s condition was reported by the examiner as due to macular degeneration. During the examination, and in other records provided to the RO, the Veteran states that he receives treatment from Dr. Boshinski for his eyes. The RO should obtain these records. The RO granted entitlement to service connection for shingles in a May 2020 rating decision. The Veteran has claimed that his eye issue is a result of shingles virus. The RO should obtain an addendum opinion after the examiner has a chance to review the medical records and then opine on whether the Veteran’s eye condition is related to active service, to shingles, or to any other service-connected disability. The Veteran also mentioned in the November 2015 Board hearing that he reported having double vision in September 1970, which would be in the month following his release from active duty. The matters are REMANDED for the following action: 1. Contact the Veteran and determine if the grant of entitlement for service connection for left upper extremity radiculopathy satisfies his claim for left arm/shoulder condition. 2. Contact the Veteran and determine if the grant of left lower extremity radiculopathy related to service-connected lumbar spine satisfies his claim for left leg/hip condition. 3. Contact the Veteran for permission to obtain the medical records from Dr. Boshinski, the eye doctor mentioned by the Veteran as treating his eye conditions, then follow the procedures to obtain the records unless it becomes obvious that such attempts are futile. 4. If the Veteran is not satisfied with the current status of service connection for left upper extremity radiculopathy as satisfying a claim for left arm/shoulder condition, please request an addendum opinion from a qualified medical examiner. The examiner should review the Veteran’s records, including the August 2019 VA examination and opinion, and answer the following: (a.) Does the Veteran have a currently diagnosed left arm or left shoulder condition that is a result of event or injury during active service? (b.) Does the Veteran have a currently diagnosed left arm or shoulder condition that is secondary to another service-connected disability, including but not limited to, cervical spine disability? 5. If the Veteran is not satisfied with the current status of service connection for left lower extremity radiculopathy as satisfying a claim for left leg/hip condition, please request an addendum opinion from a qualified medical examiner. The examiner should review the Veteran’s records, including the prior August 2019 VA examination and opinion, and answer the following: (a.) Does the Veteran have a currently diagnosed left leg or hip condition that is a result of event or injury during active service? (b.) Does the Veteran have a currently diagnosed left leg or hip condition that is secondary to another service-connected disability, including but not limited to, lumbar spine disability? 6. After obtaining the records (or making the required attempts to obtain) from Dr. Boshinski, obtain an addendum opinion from a qualified medical examiner for the Veteran’s claim for service connection for eye condition. The examiner should review the Veteran’s records and opine whether the Veteran has an eye condition that is a result of an event or injury in service, or is secondary to a service-connected disability, including but not limited to, shingles. The examiner should also comment on the Veteran’s statement in the Board hearing that he reported double vision in September 1970. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Miller, 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.