Citation Nr: 21028256 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 16-32 335 DATE: May 10, 2021 REMANDED Entitlement to service connection for a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1998 to January 1999 and from October 2004 to August 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). When this case was last before the Board in February 2020, it was remanded for additional development. Specifically, the RO was instructed to obtain the Veteran's SSA records. The relevant records were obtained. As such, the Board finds that the AOJ substantially complied with the directives in the February 2020 remand. See Stegall v. West, 11 Vet. App. 268, 271 TBI To date, the Veteran has not been afforded a VA examination to address the etiology of his claimed TBI. The Board finds that examinations and medical opinions are necessary to determine if the Veteran's claimed conditions were caused or aggravated by his military service. The Veteran's service treatment records (STRs) do not contain any complaints of, or treatment for, a TBI. However, the Veteran's VA treatment notes indicate that he had several in-service exposure incidents. Specifically, the Veteran reported being exposed to multiple IED explosions, during one of which he lost vision for 10 minutes, and another incident where the Veteran reported being knocked over by .50 caliber gunfire and was unable to focus his eyes for 2 to 3 minutes. See June 2015 Psychiatric treatment notes; see also October 2012 Mental health notes. Additionally, in a May 2015 Neurology Consult note, the Veteran's physician noted despite a normal MRI in 2011 he may be experiencing post-concussive seizures due to his in-service head trauma. Further, May 2016 treatment notes indicate that the Veteran had a TBI in 2005, while April 2016 Neurology treatment notes indicate that the Veteran is presenting with seizures, headaches, and cognitive changes that could be secondary to the injury, but note the Veteran is a poor historian and the cause is not certain. Based on the foregoing, the Board finds an examination and medical opinion is necessary to determine whether the Veteran's claimed condition was caused, or aggravated, by his active military service. The matters are REMANDED for the following action: Afford the Veteran a VA examination by an examiner with sufficient expertise to address the etiology of the Veteran's claimed TBI. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state whether the Veteran's claimed TBI at least as likely as not (a 50 percent probability or greater): originated during his period of active service or are otherwise etiologically related to his active service. The examiner must provide a complete rationale for all proffered opinions. If an examiner is unable to provide any required opinion, he or she should explain why. If an examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Gresham 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.