Citation Nr: 21041262
Decision Date: 07/08/21	Archive Date: 07/08/21

DOCKET NO. 18-43 676
DATE: July 8, 2021

REMANDED

Entitlement to an evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) is remanded.

Entitlement to service connection for a traumatic brain injury (TBI) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 2004 to January 2006, and from July 2006 to January 2007.

In June 2021, the Veteran testified before the undersigned at a hearing.  The transcript from the hearing has not yet been associated with the file, as the appeal is being remanded under the Board's "One Touch" program.  The hearing transcript will still be processed and associated with the claims file in the ordinary course of business.

1.  Entitlement to an evaluation in excess of 50 percent for service-connected PTSD is remanded.

The Veteran underwent a VA PTSD examination most recently in March 2015.  At the June 2021 hearing, the Veteran testified that his service-connected PTSD disability had increased in severity.  In light of this assertion and the fact that he has not been provided a pertinent VA examination in approximately 6 years, the Board finds that this issue should be remanded in order to schedule the Veteran for a new VA examination documenting the current severity of his service-connected PTSD.

Additionally, on remand, all outstanding VA and Vet Center treatment records should be associated with the claims file. 

2.  Entitlement to service connection for a TBI is remanded.

The Veteran is seeking service connection for a TBI.  Specifically, he has asserted that he was hit by an improvised explosive device (IED) while serving in Iraq and was knocked unconscious, which probably resulted in a TBI and concussion at the time.  See VA Form 9, September 2018. 

In a March 2015 VA opinion, the examiner noted that the Veteran claims to have been dazed by an IED.  The examiner noted that his TBI was mild and it is unlikely for a mild TBI to result in any permanent residuals.  

In a December 2016 VA treatment record, the Veteran reported headaches off and on since an IED blast.  

In light of the fact that the March 2015 VA examiner indicated that the Veteran had a mild TBI that did not result in permanent residuals, but the Veteran complained of off and on headaches since an IED blast in a December 2016 VA treatment record, the Board finds that a new VA opinion should be obtained on this matter. 

The matters are REMANDED for the following action:

1. Associate with the claims file all outstanding treatment records from the Fayetteville VA Medical Center (VAMC) and associated outpatient clinics from March 2018 to the present.

2. Associate with the claims file all outstanding treatment records from the Fayetteville, Arkansas, Vet Center. 

3. Schedule the Veteran for an appropriate VA examination to ascertain the current severity and manifestations of his service-connected PTSD.

4. Schedule the Veteran for a VA examination for his claimed TBI.  All appropriate tests and studies should be performed, and all clinical findings reported in detail.  The claims file should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed.  

After reviewing the file, examining the Veteran, and noting his reported history of symptoms, the examiner should determine whether the Veteran currently has any residuals of the previously diagnosed mild TBI.  Exposure to an IED blast during service has been conceded as consistent with the circumstances of his service.

The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 

 

 

MICHELLE L. KANE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	L. Durham, 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.