Citation Nr: 21027674 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 18-38 315A DATE: May 6, 2021 REMANDED Entitlement to a rating in excess of 10 percent for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from August 1998 to August 2002. In May 2018, the Board of Veterans' Appeals (Board), in pertinent part, remanded the issues of entitlement to increased ratings for a TBI and a TDIU for further development. Specifically, the Board instructed the regional office (RO) to schedule the Veteran for VA examinations pertaining to his claims. As an initial matter, the Board notes that the RO granted the Veteran's claim for a TDIU, effective May 4, 2016, in a February 2021 rating decision. The Veteran has not filed a notice of disagreement as to the effective date assigned. As such, the issue of entitlement to a TDIU is no longer before the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). 38 U.S.C. § 7107(a)(2). Upon review of the record, the Board finds that the claim must be remanded. The Board sincerely regrets the additional delay caused by this remand but wishes to assure the Veteran that it is necessary for a full and fair adjudication of his claim. Entitlement to a rating in excess of 10 percent for TBI is remanded. The Board finds that a new examination is warranted for the Veteran's claim. The Veteran contends he is entitled to an increased rating for his TBI. The Veteran appeared for a VA examination in February 2021, in which examiner only marked headaches as residuals attributable to a TBI. However, she went on to note that the Veteran has additional confirmed diagnosis of posttraumatic stress disorder (PTSD), depression, and anxiety and that it was not possible to differentiate the symptoms of TBI and each acquired psychiatric disorder due to similar symptomatology. Under Diagnostic Code 8045 for TBI, emotional/behavioral dysfunction is to be evaluated under 38 C.F.R. § 4.130 when there is a diagnosis of a mental disorder. The February 2021 examiner did not perform a mental disorders VA examination despite finding diagnoses of three different acquired psychiatric disorders. Accordingly, remand for a new examination to ascertain the current severity of the Veteran's TBI is warranted. Moreover, during his Board hearing, the Veteran described additional symptoms that he believed were residuals of his TBI. Specifically, the Veteran described seizures, frequent lapses of short-term memory or forgetfulness, weakness, difficulty falling asleep and staying asleep, seeing bright lights on waking, disjointed thoughts on waking, panic attacks, and anxiety. See August 2020 Board Hearing. The examiner did not comment on whether these symptoms were related to the TBI and how they factored into the examiner's evaluation of the Veteran's residuals. On remand, the examiner must address these symptoms. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination to determine the current severity of any residual symptoms from his TBI. A copy of the claims file, to include a copy of this Remand and the Veteran's August 2020 Board hearing transcript, should be sent to, and reviewed by, the examiner. A complete history of the Veteran's TBI symptoms should be elicited from the Veteran. All appropriate testing should be conducted, including the TBI rating template, and the examiner should identify all related TBI symptoms. The examiner must provide a complete rationale for all the findings and opinions. (a) The examiner is asked to include all subjective complaints and objective symptoms of the Veteran's service-connected TBI residuals. The examiner must address the degree to which the service-connected disability is manifested by facets of cognitive impairment including: memory, attention, concentration, executive functions; judgment; social interaction; orientation; motor activity; visual spatial orientation; subjective symptoms; neurobehavioral effects; communication; and consciousness. The examiner must specifically take into account the Veteran's complaints noted during his August 2020 Board hearing, including seizures, frequent lapses of short-term memory or forgetfulness, weakness, difficulty falling asleep and staying asleep, seeing bright lights on waking, disjointed thoughts on waking, panic attacks, and anxiety. See August 2020 Board Hearing. (b) The examiner must specifically conduct an additional mental disorders VA examination as the Veteran has confirmed diagnoses of PTSD, depression, and anxiety. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic and requests flexibility and understanding in affording the Veteran an opportunity for an examination. If an in-person examination cannot be provided, consider other appropriate alternatives, such as a telehealth examination. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. L. Park, 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.