Citation Nr: 21026105 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 12-21 368A DATE: April 29, 2021 REMANDED Entitlement to a rating in excess of 10 percent disabling for post-traumatic headaches is remanded. Entitlement to an initial rating in excess of 10 percent disabling for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1987 to February 1992, with additional service in the Ohio Army National Guard. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a December 2009 rating decision by a Department of Veterans Affairs Regional Office (RO). In January 2016, the Veteran testified at a videoconference hearing before the undersigned. A transcript of that hearing has been associated with the claims file. During the pendency of the appeal, a June 2020 rating decision granted an increased rating for TBI of 10 percent, effective the date of claim; October 23, 2008. 1. Post-Traumatic Headaches 2. TBI In December 2020, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to readjudicate the claims on appeal, including raised claims for extraschedular consideration. The Board notes that the requested supplemental statement of the case (SSOC) was issued in December 2020. The Board further notes that since the most recent November 2019 VA examinations, the Veteran has asserted worsening symptoms for both claims on appeal. In this regard, in a September 2020 statement, the Veteran asserted that his migraine condition limited his social interaction by limiting his contact with the public. In this regard, the Veteran reported that he tended to shop early in the morning when less people were around, and that he tended to stay away from events that caused loud noises. In addition, the Veteran reported that his migraine and TBI symptoms affected his ability to stand for prolonged periods of time or his ability to bend at the waist due to causing bouts of vertigo leading to increased migraine episodes. In addition, the Veteran reported that he had migraines 2 to 3 times per month with episodes lasting 24 hours or more preventing him from getting out of bed and causing him to miss work. In a January 2021 letter, the Veteran stated that within the past 6 months, he had experienced several bouts of vertigo, including episodes resulting in hospitalization. The Veteran’s spouse also submitted a letter in January 2021, and asserted that the service-connected migraine and TBI conditions with associated vertigo had impacted his health, employment, and family relationships. With regard to vertigo, the spouse asserted that she began to notice serious balance issues approximately 5 years prior, and that the Veteran had fallen several times with precipitating symptoms of headaches and dizziness. In November 2020, the spouse stated that the Veteran passed out, fell, and hit his head in the bathroom, and that his TBI doctor had issued him a Life Alert to wear when at home alone. In addition, she noted that the Veteran had been prescribed a cane for stability and had been referred to the pain clinic for his migraines. With regard to the November 2019 VA headache examination, the Board notes that at that time, the Veteran’s symptoms included nausea and sensitivity to light, and the examiner concluded that the headache condition was not manifested by very prostrating and prolonged attacks productive of severe economic inadaptability. Accordingly, with regard to his service-connected headache condition, since the November 2019 VA examination, the Veteran has reported more severe symptomatology. With regard to the November 2019 VA TBI examination, the Board notes that the examiner found the condition manifested no worse than level 1 for memory, attention, concentration and executive functions (facet 1), and subjective symptoms (facet 7). For subjective symptoms, the examiner noted symptoms of headaches and insomnia. Accordingly, with regard to his service-connected TBI condition, since the November 2019 VA examination, the Veteran has reported more severe symptomatology. Evidence of a change in the condition or allegation of worsening of the condition renders an examination inadequate for rating purposes. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007); see also Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Given the Veteran’s assertion that his service-connected headache and TBI conditions have worsened since his last VA examinations, and recently added medical records evidencing that the conditions have worsened, a remand is warranted for new VA examinations. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board additionally notes that a review of the November 2019 TBI examination notes the examiner was a physician of internal medicine. There is no indication that the examiner was a clinician who had successfully completed the DEMO (CPEP) TBI training module. In this regard, it is noted that VA policy states that health care providers who may conduct TBI examinations include physiatrists, psychiatrists, neurosurgeons, and neurologists, as well as generalist clinicians who have successfully completed the DEMO (CPEP) TBI training module. C&P TBI certified clinicians are permitted to perform TBI residual disability examinations subject to existing VBA guidance on examiner qualification, including M21-1MR, III.iv.3.D.18.b. Such guidance was also noted on the face of the November 2019 VA examination itself. As there is no indication that the examiner who performed the November 2019 VA TBI examination met the aforementioned requirements, the Board finds that efforts should be made to determine whether the November 2019 VA examiner successfully completed the DEMO (CPEP) TBI training module. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Verify the November 2019 VA TBI examiner’s credentialing information, to include whether the examiner successfully completed the DEMO (CPEP) TBI training module. 3. Then, schedule the Veteran for an examination by an appropriate examiner to determine the current nature and severity of his service-connected headache condition. The examiner is asked to consider the Veteran’s reported symptoms, including vertigo. 4. Then, schedule the Veteran for a VA examination to determine the current severity of his service-connected TBI with residuals. (Continued on the next page) The examiner is asked to consider the Veteran’s reported symptoms, including vertigo. The examiner should review the evidence associated with the record. All indicated tests and studies necessary to evaluate the Veteran under the appropriate rating criteria should be completed. The examiner should identify the nature, frequency, and severity of all current manifestations of the Veteran’s TBI and associated psychiatric disorder and specify the degree of occupational or social impairment. All symptoms and clinical findings of the Veteran’s TBI and residuals should be reported in detail, to include the functional impact of such in consideration of both medical and lay evidence. H.N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lamb, 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.