Citation Nr: 21041895 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-52 029 DATE: July 10, 2021 REMANDED Entitlement to service connection for residuals of a head injury, to include residuals of a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1964 to January 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision. In August 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The Veteran's claim for service connection was remanded in February 2020, December 2020, and May 2021 by the Board for further development. Unfortunately, the Veteran's claim must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim, so he is afforded every possible consideration. Entitlement to service connection for residuals of a head injury, to include residuals of a TBI is remanded. The Veteran's claim for service connection was remanded by the Board in May 2021, in part, to obtain addendum medical opinion concerning the etiology of any residuals of his in-service head injuries. The examiner was also directed to determine the etiology of certain identified disabilities, including headaches, loss of balance, subarachnoid cyst, neurosarcoidosis, smooth dural enhancement of supra-tentorial and infra-tentorial spaces, and/or abnormalities shown on the brain Magnetic Resonance Imaging (MRI) scan from February 2019. The Veteran's claims folder contains several medical opinions obtained after the May 2021 remand. Of note, a May 2021 medical opinion states that there are no residuals attributable to a head injury because there is no diagnosis of a TBI given in the February 2020 Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) Disability Benefits Questionnaire. The Board finds that the above May 2021 medical opinion is inadequate because it does not explain why a diagnosis of a TBI is necessary for any residuals of a head injury to be connected to his in-service head injuries. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") An additional May 2021 medical opinion states that the Veteran's headaches are not attributable to a head injury because there is no diagnosis of a TBI contained in the February 2020 Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) Disability Benefits Questionnaire. The medical opinion further provides that the February 2020 examination report does not note residual TBI related headaches and his other medical conditions and findings noted on his MRI likely contribute to his headaches. Again, the Board finds the May 2021 medical opinion is inadequate because it does not explain why the Veteran's headaches cannot be attributed to in-service head injuries because of a lack of residual TBI related headaches noted on the February 2020 examination report. See Barr, 21 Vet. App. at 312; see also Stefl, 21 Vet. App. at 124. The medical opinion also fails to advise of the other medical conditions and findings noted on his MRI that likely contribute to his headaches. Id. Therefore, an addendum medical opinion is warranted to determine the nature and etiology of any residuals that the Veteran currently has from his in-service head injuries. The matter is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from June 2021 to the present. 2. After the above development is completed, obtain an addendum medical opinion from an appropriate clinician. If the clinician determines that an additional examination (or telehealth interview) of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled; however, the Veteran should not be required to report for another examination (or telehealth interview) as a matter of course, if it is not found to be necessary. The examiner must review the claims folder. The examiner must: (a.) Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has any current residuals related to his in-service head injuries. (b.) Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's headaches and/or loss of balance are related his in-service head injuries. In providing the above opinions, the examiner should consider: The service treatment record showing that the Veteran was seen in the emergency room following an automobile accident on April 6, 1964, and the corresponding skull X-ray; The service treatment record demonstrating that the Veteran was seen in the emergency room on October 31, 1964, after suffering a head injury while jumping on a trampoline; The service treatment record dated November 6, 1964, noting that the Veteran continued to have headaches; The Veteran's statements that he suffered a head injury during service when he was thrown from a truck and landed on his back; while he did not lose consciousness, he reportedly suffered from headaches and back pain a few days later; and he did not report this incident because he did not want to get the driver of the truck in trouble; (Continued on the next page) Service treatment records from February 2, 1965 that show he was seen for a dressing change and February 5, 1965 for his back and check of a scalp laceration. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mussey, Sean 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.