Citation Nr: 21029072 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 14-05 560 DATE: May 12, 2021 REMANDED Entitlement to service connection for residuals of traumatic brain injury (TBI) is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1978 to April 1979. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a March 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) following the Veteran's application for service connection in which he claimed head trauma began in 1982. In that decision, the RO denied service connection for head trauma, noting the Veteran's reports of injuring his head during basic training and of experiencing headaches and blackouts, but found no documentation of complaints, treatment, or diagnosis during service. The March 2012 rating decision on appeal also denied service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and major depression. The Veteran attended a VA examination conducted by a neurology staff physician in September 2014 conducted in connection with a claim for service connection headaches. However, head trauma was not addressed. In November 2017, the Board remanded the case for a TBI examination to determine the nature and etiology of any current residuals of a head trauma and to opine whether the head trauma was caused or aggravated by Veteran's military service. In the same decision, the Board remanded the claim of service connection for an acquired psychiatric disorder for a separate examination. In August 2018, the Veteran was afforded a VA examination for PTSD by a psychologist. Regarding whether the Veteran had a diagnosed TBI, the examiner noted that it was not shown in records reviewed. The examiner did not attempt to evaluate whether the Veteran may have a TBI. In April 2019, the Veteran attended a VA examination by a physician regarding the central nervous system and neuromuscular diseases. The examination form used specifically excluded traumatic brain injury. In the examination report, the April 2019 VA physician wrote the Veteran had a normal neurological examination and there was no evidence in the medical record, in brain imaging tests, or in the history provided by the Veteran that he had any neurological symptoms related to head trauma. He concluded that he did not see any head trauma residuals. In September 2019, the Board denied the claims for service connection for TBI and residuals and service connection for an acquired psychiatric disorder to include PTSD and depression. The Veteran appealed the September 2019 Board decision denying service connection for head trauma to the United States Court of Appeals for Veterans Claims (Court). In a December 2020 Order, the Court granted a Joint Motion for Partial Remand (Joint Motion) filed by the parties to vacate and remand the portion of the September 2019 Board decision denying entitlement to service connection for head trauma. The denial of service connection for an acquired psychiatric disorder was not disturbed. Due to the incorrect examination report obtained pertaining to head trauma and TBI, the parties agreed a remand was warranted for the Board to determine whether there was substantial compliance with the Board's November 2017 remand order, and whether further development was warranted, to include a TBI examination. Entitlement to service connection for residuals of TBI is remanded. A remand is warranted based on the review conducted pursuant to the instructions of the parties to the joint motion. Despite indications the Veteran suffers from head-related symptoms and his reported history of concussions, it is not clear that the Veteran has a current diagnosis of TBI. If VA provides an examination, and there is no established diagnosis of TBI, a qualified specialist should conduct the examination. Additionally, VA should ensure that the correct examination has been ordered, an appropriate report is produced such as on a specific TBI form, and the necessary and outstanding medical questions relevant to the Veteran's claim are addressed. However, the current examinations of record do not meet these criteria. Therefore, a remand is necessary for an adequate examination. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: Schedule the Veteran for a VA examination conducted by a health care provider who is qualified to diagnose TBI, and to determine the nature and etiology of any current residuals of head trauma. The claims file, including a copy of this remand, should be made available to the examiner. Any studies, tests, and evaluations deemed necessary by the examiner must be performed. The TBI examiner should identify any current disability residual to head trauma. The examiner is asked to answer the following questions: Does the Veteran have a current diagnosis of TBI or head trauma? Are any current head trauma residuals related to the Veteran's military service? The examiner should also indicate whether there was a preexisting disorder relating to head trauma and, if so, whether it was aggravated by the Veteran's military service. In answering the above, the examiner is advised that the Veteran is competent to report symptoms, treatment, and injuriesto include that he fell and hit his head while climbing an obstacle course rope during basic training -and that his reports must be taken into account in formulating the requested opinions. The examiner should provide complete rationale for each opinion expressed and conclusion reached. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Kuczynski, 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.