Citation Nr: 21030814 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-53 606 DATE: May 19, 2021 REMANDED The service connection claim for a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2002 to April 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In November 2019 the Veteran and his spouse, B.B., testified at a November 2019 hearing at VA's Central Office, before the undersigned Veterans Law Judge. A transcript of this hearing is of record. In March 2020, the Board remanded this matter to the RO for further evidentiary development. While the Board regrets any further delay, additional developments are required before it can render a fully informed decision on the service connection claim for TBI. At his Board hearing, in November 2019, the Veteran testified that he cracked his head open on the back of a Humvee vehicle during his active service. He reported having symptoms of headaches, and that he is constantly supersensitive to light, which requires him to wear sunglasses when he drives at night; and that in July 2014, he was screened and found positive for TBI. Although August 2015 and July 2020 VA examination reports indicate that a TBI diagnosis and/or residuals could not be confirmed, post-service medical treatment records confirm that the Veteran has symptoms of headaches, sensitivity to bright light, and that he is diagnosed with mild TBI. See e.g. July 2006 Primary Care Initial Evaluation Note; see also July 2014 Addendum and Traumatic Brain Injury Screening; see too, October 2016 Psychology Administrative Note (reporting that the Veteran was evaluated in 2014, as part of his TBI evaluation, and that the evaluation results revealed a positive history for TBI); see too, February 2020 Private Treatment Note. The evidence of record also entails evidence of an in-service injury and event that may be related to the Veteran's current, TBI diagnosis. Service treatment records (STRs) confirm that the Veteran walked into the rear of a vehicle, without a helmet, he had an acute onset of bleeding from his head; and he also sustained a 212 cm linear laceration to the forehead. See February 2003 Chronological Record of Medical Care. Additionally, an August 2014 TBI note further confirms that in Iraq, in January 2003, the Veteran ran into the back of a vehicle; he had blood dripping all over his face; and he had staples in his scalp (midline, near the forehead, just at the edge of his hairline);and that between 2003 and 2004, after a mortar landed 10 feet away from him, shaking the ground, he was dizzy and saw stars, although he did not lose consciousness. Thus, as there is evidence of an in-service injury and events that may be correlated with the Veteran's current TBI, a remand is required for a VA examination and opinion on the nexus between the Veteran's in-service injury and event and his TBI. See McClendon v. Nicholson, 20 Vet. App. 79, 85 - 86 (2006). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for traumatic brain injury to assess the nature and etiology of his traumatic brain injury. This VA examination must be conducted by one of four of the following specialists: a neurologist, psychiatrist, physiatrist, or neurosurgeon (VA examiner). The VA examiner must review a complete claims file and must note that review in the report. A copy of this REMAND must also be provided to the VA examiner. The VA examiner must undertake the following: a. Opine whether it is at least as likely as not (more than 50 percent probability) the Veteran s TBI is the result of an in-service injury, illness or event; was incurred in active service; and/or is otherwise related to his active service. b. The Veteran is a combat Veteran and his statements about an in-service injury and events are presumed credible and consistent with the time, place and circumstances of his service. See 38 U.S.C. § 1154(b); see also Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). Therefore, in establishing an opinion, the Veteran's lay statements, including and not limited to, his reported in-service accident and injury, as well as TBI-related symptoms, such as, for example, headaches and sensitivity to light, should be considered. (Continued on the next page) c. The VA examiner must consider and discuss all pertinent evidence, especially including the July 2014 addendum, which indicates that the Veteran has a TBI diagnosis. If there are discrepancies with any findings in medical treatment records, please provide an explanation, with a clear rationale. d. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V-N. Pratt 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.