Citation Nr: 21023801 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 18-26 025 DATE: April 21, 2021 REMANDED Entitlement to service connection for traumatic brain injury (TBI) is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2012 to May 2015. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, inter alia, denied service connection for TBI, a left knee disability, and bilateral hip disabilities. In January 2021, the Veteran testified at a tele-hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. 1. Entitlement to service connection for TBI is remanded. The Veteran contends that his TBI is the result of a head injury he sustained while on active duty. See January 2021 Transcript of Hearing, pages 2-6. A March 2015 entry in the Veteran’s service treatment records (STRs) noted an intracranial injury without skull fracture and history of concussion. See March 2015 Medical Record. The Veteran was afforded a VA examination for TBI in December 2015. The examiner found no objective findings to support a diagnosis of the claimed TBI and noted, inter alia, that the Veteran had no complaints of impairment of memory, attention, concentration, or executive functions. The Veteran was also afforded a VA examination for mental disorders in December 2015. The examiner determined that the Veteran did not have a diagnosed TBI. The examiner noted the Veteran’s complaints of concentration and memory problems, but found they were unrelated to any in-service event. In pertinent part, the Veteran’s VA treatment records note a history of TBI and ongoing complaints regarding difficulties related to memory, attention, and concentration. See 2016-2020 VA treatment records. The Veteran was most recently afforded a VA examination for mental disorders in March 2018. The examiner found that the Veteran had a diagnosed TBI and also noted diagnoses of unspecified anxiety disorder and depressive disorder. The examiner noted the Veteran’s complaints of mild memory problems, irritability, forgetfulness, ruminating thoughts, depressed mood, persistent worry, and sleep disturbances and indicated that it was not possible to differentiate which symptoms were attributable to each diagnosis. The examiner also noted that the Veteran’s TBI appeared to exacerbate his mood symptoms. At the January 2021 Board hearing, noted above, the Veteran testified that he experienced issues with his memory due to his in-service head injury. See January 2021 Transcript of Hearing, pages 5-6. The Board finds that the December 2015 VA examinations are inadequate, as the examiners failed to consider the March 2015 entry in the Veteran’s STRs noting an intracranial injury without skull fracture and history of concussion. The Board also finds that the March 2018 VA examination is inadequate. Although the examiner found that the Veteran had a diagnosed TBI and noted symptoms to include mild memory problems, irritability, and forgetfulness, she was unable to differentiate which symptoms were attributable to the Veteran’s TBI and which were attributable to his psychiatric diagnoses and failed to offer an explanation for such. As the Veteran’s VA treatment records contain ongoing complaints regarding difficulties related to memory, attention, and concentration, which he attributes to his TBI, the Board finds that remand is warranted for a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right hip disability is remanded. 4. Entitlement to service connection for a left hip disability is remanded. At the January 2021 Board hearing, noted above, the Veteran indicated that he received physical therapy for his musculoskeletal pain through the Veterans Choice Program. However, those treatment records have not been associated with the claims file. VA has a duty to “make reasonable efforts to assist” veterans “in obtaining evidence necessary to substantiate” their claims. 38 U.S.C. § 5103A(a)(1). This duty includes obtaining “VA medical records or records of examination or treatment at non-VA facilities authorized by VA,” so long as there is enough information for VA to adequately identify and locate them. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016); 38 C.F.R. § 3.159(c)(3) (2020). VA also has a has a duty to obtain VA records regardless of their relevance to the present claim. See Sullivan, 815 F.3d at 793. But VA is not required to search (or continue searching) for records if “‘no reasonable possibility exists that such assistance would aid in substantiating the claim.’” Jones v. Wilkie, 918 F.3d 922, 926 (Fed. Cir. 2019) (quoting 38 U.S.C. § 5103A(a)(2)). Thus, remand is warranted to enable the RO to undertake the necessary efforts to attempt to obtain these records. Accordingly, the matters are REMANDED for the following action: 1. After obtaining the necessary information and authorization from the Veteran, undertake the necessary efforts to obtain records of the Veteran’s physical therapy treatment from Physical Therapy Services of Brooksville, or any other facility authorized by the VA that may have treated the Veteran, and associate those documents with the claims file. 2. Schedule the Veteran for an examination by an examiner with appropriate expertise to determine the nature and etiology of the claimed TBI. The examiner should either diagnose or rule-out residuals of a head injury, to include TBI. In rendering this finding, the examiner should address the Veteran’s STRs noting an intracranial injury without skull fracture and history of concussion and the March 2018 VA examination report indicating a diagnosed TBI, as well as the Veteran’s reported symptoms of difficulties related to memory, attention, and concentration, referenced above. As to any diagnosed residuals of a head injury, to include TBI, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, to include the in-service intracranial injury. (Continued on the next page)   The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. All examination findings/testing results, along with complete, clearly-stated rationales for the conclusions reached, must be provided. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ruddy, 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.