Citation Nr: 21040498 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 19-05 860A DATE: July 3, 2021 REMANDED Entitlement to service connection for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 2001 to September 2005 with service in Southwest Asia. The Veteran had subsequent reserve service from September 2005 to July 2009. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In an April 2020 Board decision, in pertinent part, denied entitlement to service connection for TBI. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In March 2021, the Court granted a Joint Motion for Remand (JMR), vacating the Board's April 2020 decision in pertinent part and remanding the case to the Board for action consistent with the JMR. The 2020 Board decision also remanded several other issues for additional development. Those issues are still in remand status and will be the subject of a later Board decision, as appropriate. Entitlement to service connection for TBI is remanded. The Veteran contends that he experienced a TBI during active duty. He reported that he is a combat Veteran and hurt his head during active service which caused his TBI. In the March 2021 JMR, the parties agreed that the Board failed to provide an adequate reasons and basis for finding that a TBI was not incurred during active service. The parties noted that the previous Board decision found that the Veteran served two tours in Iraq as a warehouseman in support of combat operations and that the incurrence of some head injuries were consistent with the place and circumstances of his service. However, the parties determined that the it was unclear whether the Board found that the Veteran suffered or did not suffer a head injury during active service. The Board finds that a remand is necessary to obtain a VA examination before a final adjudication can be entered. Here, while VA PTSD examinations conducting in January 2016 and August 2019 noted that the Veteran did not have a diagnosis of a TBI, it is unclear if these examiners considered that Veteran statements of experiencing a head injury during active service or post-service private treatment records noting diagnosis of TBI. Therefore, the Boards finds that a VA TBI examination, with an appropriately qualified examiner, should be scheduled to determine if the Veteran has a diagnosis of a TBI related to active service. The Board recognizes the contentions regarding the Veteran's status as a combat Veteran. See 4/08/2021 Appellate Brief; 3/02/2021 CAVC decision, at 4. However, prior to making this determination, the Board finds a specific TBI examination would be useful for a full and fair adjudication on merits as explained above. This matter is REMANDED for the following action: Schedule the Veteran for an appropriate VA TBI examination to be conducted by one of the four designated specialists (physiatrist, psychiatrist, neurologist, or neurosurgeon) to assess the nature and etiology of the Veteran's TBI. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies should be accomplished, or an explanation provided as to why they medically appropriate or necessary. All clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must also be provided. (a) First, the examiner must determine if the Veteran has a current diagnosis of TBI proximate to or since the Veteran fied a claim with VA in September 2015. Please explain why or why not. If the Veteran is not diagnosed with a TBI, then the examiner must address the private March 2020 disability benefits questionnaire (DBQ) showing a diagnosis of TBI. (b) Second, if the Veteran has a diagnosis of TBI, the examiner must provide an opinion regarding whether it is at least as likely as not (probability of approximately 50 percent) that the residuals of TBI had their onset in, or are otherwise related to, the Veteran's active service. **The examiner must consider the Veteran's lay statements regarding TBI onset and symptomology. See, e.g., 10/19/2015 VA 21-4138. Additionally, please also address the submitted article "Consequences of Repeated Blood-Brain Barrier Disruption in Football Players". See 4/08/2021 Correspondence.** A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dworkin, 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.