Citation Nr: 21029932 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 17-42 823 DATE: May 17, 2021 REMANDED Entitlement to service connection for traumatic brain injury (TBI) (also claimed as ischemic disease) is remanded. REASONS FOR REMAND This appeal comes before the Board of Veterans' Appeals from a May 2016 Department of Veterans' Affairs (VA) Regional Office (RO) denying service connection for a traumatic brain injury (also claimed as ischemic disease). The Veteran timely appealed the decision to the Board. A hearing was held in July 2020 before the undersigned Veterans Law Judge (VLJ). A full transcript of the hearing is contained in the record. Upon reviewing the record, the Board finds that additional efforts should be undertaken to obtain potentially outstanding medical records. The Veteran identified private treatment providers prior to appealing the claim to the Board; these include private treatment records for the Veteran's condition before and after his deployment to Kuwait in 2006. Additionally, during the July 2020 hearing, the Veteran's representative relayed that the Veteran received treatment at Camp Navistar, Camp Arifjan, and Kuwait Navy Base during his deployment. While the claims file indicates that the RO requested the Veteran's in-patient treatment records from Kuwait Navy Base in 2006, there is no indication that a response was received that specifically address the existence (or nonexistence) of these records, or that attempts were made to obtain records of any treatment from these other military bases. Accordingly, a remand is necessary to obtain these private and service records, or adequately document their unavailability. Moreover, the RO has not undertaken sufficient efforts to verify the Veteran's report of experiencing a mortar attack in April 2006 during his deployment to Kuwait; efforts must be made to verify his reported in-service injury. The Board also notes that the medical evidence does not include a VA examination that adequately evaluates whether the Veteran has a TBI. A May 2016 VA headaches examiner noted that there is "vague mention of a possible TBI" and stated that the disorder "was not clear, and perhaps should be explored." Thus, the claim must be remanded to provide the Veteran with an appropriate VA examination for his possible TBI. The matters are REMANDED for the following action: 1. Invite the Veteran to submit copies of any relevant treatment records, to include all private treatment records. Request medical release forms to obtain records from all identified private treating physicians identified in the record, including the following: S.M. in Merchantville, NJ; Dr. J.Y.; S.D. in Cherry Hill, NJ; Dr. G.B.; and the Department of American Board of Psychological Neurology in Maple Shade, New Jersey. All attempts and/or unavailability must be documented. 2. Obtain any missing service treatment records and personnel records, including records of any treatment and hospitalizations at Camp Navistar, Camp Arifjan, and Kuwait Naval Base Hospital records during the Veteran's deployment from January 2006 to October 2006. All attempts and/or unavailability must be documented. 3. Take all appropriate steps to verify a mortar attack at the Veteran's duty station in April 2006. All attempts to verify the incident and responses must be documented. 4. After the above development has been completed, schedule the Veteran with an appropriate medical examiner for an in-person evaluation for traumatic brain injury. The examiner is requested to identify all relevant diagnosis that may account for symptoms possibly associated with TBI, and the date of each diagnosis. The examiner's attention is directed: Veteran's headaches/migraines are documented date back to at least November 1999, pre-dating any claim for TBI in 2006; October 2007 private MRI report and findings associated with it; Private diagnosis of PTSD as of 2013; Diagnosis of sleep apnea; and 2016 motor vehicle accident in which the Veteran struck his head against the windshield. The examiner is requested to residuals associated with claimed in-service TBI, including the Veteran's report of residuals scars or marks on his head. If no such scars or markings can be identified, the examiner is asked to explain if such scars or marks would be expected to exist, and if so, opine why such are missing. (E.g., lack of scars supports no such injury, scars have healed/faded, other reason(s)). After completion of the ordered in-person an examination, the examiner must opine: (a.) Does the Veteran have a residuals of an in-service TBI? A rationale accounting for relevant symptoms including memory difficulties, headaches, sleep difficulties, increased irritability, dimming vision, etc. (E.g., are these symptoms due to a TBI or accounted for by other disabilities). (b.) If the Veteran is diagnosed with a TBI, is the Veteran's TBI more likely than not related to the claimed in-service injury, a mortar attack while stationed in Kuwait? (c.) If the answer to (a.) is positive for TBI, and the answer to (b.) is negative, is the Veteran's TBI more likely than not caused after his last period of active service? Once the additional development is completed, if the benefits sought on appeal remain denied, the Veteran and his representative should be issued an SSOC and be provided an appropriate opportunity to respond, before the case is returned to the Board. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Boushehri, Darjush M. 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.