Citation Nr: 21042520 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-62 477 DATE: July 13, 2021 REMANDED Entitlement to service connection for residuals of a traumatic brain injury (TBI), to include headaches, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2005 to March 2010. He served honorably in the U.S. Army, including service in Iraq, and is a recipient of the Combat Action Badge. The Board thanks the Veteran for his service to our country. The Board previously remanded this case in December 2018 for additional development. Pursuant to the Board remand, in June 2020, the Agency of Original Jurisdiction sent the Veteran a VA Form 21-4142, requesting that he complete and return the enclosed form in order for VA to obtain Vet Center treatment records; however, no response was received. The case has now returned to the Board for further appellate review. Entitlement to service connection for residuals of a TBI, to include headaches, is remanded. A remand is necessary for an addendum opinion. In a June 2015 VA examination report, the Veteran reported that he was deployed to Iraq twice, during which he was involved in route clearance as a 50-caliber gunner. He reported that his vehicle was hit at least 10 to 15 times by small munitions from grenades to trash bombs, which is a small blast meant to stop a convoy. He reported one major blast to his vehicle by a 155 rocket which hit the right side of the vehicle in which he was a passenger. He reported that he landed in the medic's lap and after he and his fellow soldiers checked on one another, they continued their mission. He reported that back at his camp he was seen by a field medic and, while 3 days of light duty were recommended, he and his fellow soldiers did not want to take time off. He reported no loss of consciousness associated with the event, though he may have briefly been "a little foggy." He recalled having slight headache in the vehicle after the rocket blast but not upon returning to base. The examiner concluded that he did not sustain a TBI in service as he reported a rocket blast which may have resulted in brief alteration of consciousness but not loss of consciousness, he did not have post or retrograde amnesia for the event, and he noted only mild headache after the event which was short-lived. The examiner's opinion appears to consider only the Veteran's report, six years later, and appears to be based, at least in part, on his report that he did not lose consciousness and noted only mild, short-lived headache after the event. However, the examiner did not address the Veteran's contemporaneous in service medical records endorsing multiple symptoms in addition to headaches beginning or worsening after reported events as well as being knocked out or losing consciousness and sustaining a concussion. Specifically, in January and February 2009 post deployment health assessments for the period from January 2008 to January 2009, he indicated experiencing a blast or explosion and a vehicular accident or crash after which he felt dazed, confused, or "saw stars" and from which he had a head injury. He endorsed sensitivity to bright light beginning or worsening after the reported events. Further, in a July 2009 post deployment health assessment for the period from January 2008 to February 2009, he again endorsed experiencing a blast or explosion and a vehicular accident or crash; he also endorsed sustaining a fall. He indicated that immediately after the events, he experienced loss of consciousness or getting "knocked out"; felt dazed, confused, or "saw stars"; and had a concussion. He endorsed memory problems or lapses, sensitivity to bright light, headaches, and sleep problems beginning or worsening after the reported events. Additionally, in a June 2015 headaches VA examination report, the examiner concluded that the Veteran did not have a headache disorder. As it is unclear whether the Veteran's headaches are symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness, an addendum opinion is further warranted. The matters are REMANDED for the following action: 1. Please secure for the record copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disabilities on appeal. Please ask the Veteran to provide the releases necessary for VA to secure private treatment records. 2. After the action requested in paragraph 1 is complete, please refer the claim to an appropriate clinician for an addendum opinion as to whether he has residuals of a TBI. The Veteran's claims-file must be made available to and reviewed by the clinician. The clinician is requested to opine as to the following: (a.) Did the Veteran at least as likely as not (a 50 percent or greater probability) sustain a TBI in service, the residuals of which include headaches? (b.) Are the Veteran's headaches signs or symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness (a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology)? Please explain. The clinician is requested to consider and address as appropriate the following: January and February 2009 post-deployment health assessments covering the period from January 2008 to January 2009 in which the Veteran endorsed experiencing a blast or explosion and a vehicular accident or crash; feeling dazed, confused, or seeing stars and sustaining a head injury immediately afterward; and sensitivity to bright light beginning or worsening after the reported events. A July 2009 post-deployment health assessment covering the period from January 2008 to February 2009 in which the Veteran endorsed experiencing a blast or explosion, a vehicular accident or crash, and sustaining a fall; experiencing loss of consciousness or getting "knocked out," feeling dazed or confused or seeing stars, and sustaining a concussion immediately afterward; and memory problems or lapses, sensitivity to bright light, headaches, and sleep problems beginning or worsening after the reported events. A November 17, 2010 VA polytrauma note stating that the Veteran had a negative TBI screen but further intervention was indicated by the polytrauma/TBI treatment provider. The Veteran endorsed experiencing a blast or explosion, a vehicular accident or crash, and a blow ot the head, after which he had symptoms of being dazed, confused, or seeing starts and head injury. He endorsed headaches that began or worsened afterward but denied symptoms within the past week. He reported one incident in which a large weapon fell on his head when he did not have a helmet on, resulting in an "egg" on his head and dazing him for a moment; he denied losing consciousness but reported a headache with no lasting symptoms. A June 2015 headaches VA examination report in which the Veteran reported noticing mild headaches after he got back from service and in which the examiner noted that the headaches are associated with photophobia. A June 2015 PTSD VA examination report in which the Veteran reported that he was blown up about 5 times every 6 months, 10 times per deployment with a blast around him and three times per deployment while inside a vehicle. He reported one really bad blast. ONLY IF the clinician determines that an examination is necessary for the addendum opinion, the Veteran should be scheduled for an appropriate VA examination. The clinician must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the clinician cannot provide an opinion without resorting to speculation, the clinician should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Vashaw, Associate 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.