Citation Nr: 21025549 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-46 404 DATE: April 28, 2021 REMANDED A rating in excess of 10 percent for traumatic brain injury (TBI) is remanded. Service connection for right upper extremity nerve damage is remanded. Service connection for left arm numbness is remanded. Service connection for left leg tingling is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1998 to December 2006. The Veteran testified before the undersigned Veterans Law Judge at an October 2019 video-conference hearing. A complete transcript is of record. This appeal was previously before the Board in January 2020. Following certification of the appeal, in February 2018, VA obtained additional pertinent evidence, in the form of VA treatment records. The Veteran declined to waive consideration of this evidence by the originating agency. As such, the January 2020 Board decision remanded the appeal for consideration by the originating agency in the first instance. The Veteran’s appeal was considered by the Agency of Original Jurisdiction (AOJ) and he was issued a supplemental statement of the case (SSOC) in September 2020, which addressed all the issues on appeal. As such, the Board finds that there has been substantial compliance with the Board remand directives, as they pertain to AOJ review. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A rating in excess of 10 percent for TBI is remanded. Although there has been substantial compliance with the Board remand directives as they pertain to AOJ review, the Board nonetheless finds that another remand is necessary. Regarding the Veteran’s increased rating claim for TBI, the Board notes that the January 2020 Board remand directives also ordered a VA TBI examination to ascertain the current nature and severity of his service-connected TBI. He was afforded a VA TBI examination in September 2020. After the examination, VA received correspondence from the Veteran, stating that the TBI examination was inadequate because it was only five minutes, that covered nothing other than him drawing hands on a clock and 4-5 words on a paper. See Correspondence received October 9, 2020. To the extent that the Veteran has asserted that the September 2020 VA examination was inadequate, the Board agrees. The Board notes that the Veteran has consistently complained of blackouts, lightheadedness, and dizziness. However, the examination report notes no subjective symptoms and there is no acknowledgment of such symptoms anywhere else in the examination report discussing an assessment of the facets of a TBI rating. Further, the October 2020 correspondence also reported that the Veteran has memory and concentration issues, but the September 2020 VA examiner reported that there were no complaints of impairment of memory, attention, concentration, or executive functions. Here, the Board finds that although the Veteran was afforded a VA TBI examination in September 2020, it was inadequate and the Veteran should be afforded new VA examination that takes into account all of his reported TBI symptoms. Accordingly, the increased rating claim for TBI is remanded. Service connection for right upper extremity nerve damage, left arm numbness, and left leg tingling is remanded. Regarding the Veteran’s service connection claims for bilateral upper extremity and left lower extremity nerve damage, the Board finds that a remand is also necessary. The Board notes that the Veteran was afforded VA examinations for his nerve damage claims in March 2017. The VA examiner explained that there was no evidence to support a diagnosis for a persistent disability for either the upper extremities or the left lower extremity. However, the Veteran has continued to describe neurologic problems in the arms and left leg. See Correspondence received October 9, 2020. He stated that he did not experience nerve issues prior to having surgery on his right and left shoulders. Here, the last VA examination for his reported nerve conditions was about four years ago and the Board finds that new VA examinations are necessary to ascertain whether the Veteran’s continued complaints of nerve problems have manifested to a diagnosable disability, and if so, whether they are related to his service-connected disabilities. The Board also notes that the Veteran indicated that he submitted multiple documents to his representative, to be sent to the Board. However, he noted that according to the comments in the SSOC, it appeared to him that they were never forwarded the documents. The Board finds that the AOJ should work with the Veteran and his representative to ensure that all available medical records have been obtained and associated with the claims file. Accordingly, the service connection claims for right upper extremity nerve damage, left arm numbness, and left leg tingling is remanded. The matters are REMANDED for the following action: 1. The AOJ should contact the Veteran, and, with his assistance, identify any additional outstanding records of pertinent medical treatment pertaining to his TBI and/or neurologic conditions. 2. After any additional records are associated with the claims file, the AOJ should schedule the Veteran for a VA TBI examination. The Board notes that the September 2020 VA TBI examination was found to be inadequate because the Veteran’s reported symptoms of TBI were not acknowledged or addressed in the evaluation of his TBI. 3. Schedule the Veteran for VA peripheral nerve condition examination to ascertain whether he has any nerve disabilities in his upper extremities and/or left lower extremity. (a) Should any upper extremity disability be diagnosed, the examiner should provide the following opinions: Is it at least as likely as not (50 percent or greater probability) that an upper extremity condition is proximately due to or caused by the service-connected shoulder disability? Why or why not? Is it at least as likely as not (50 percent or greater probability) that an upper extremity condition has been aggravated (made worse) by the service-connected shoulder disability? Why or why not? (b) Should there be a diagnosis for a left lower extremity condition, the examiner should provide: the following opinions: Is it at least as likely as not (50 percent or greater probability) that a left lower extremity condition is proximately due to or caused by the service-connected low back disability? Why or why not? Is it at least as likely as not (50 percent or greater probability) that a left lower extremity condition has been aggravated (made worse) by the service-connected low back disability? Why or why not? MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fu, 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.