Citation Nr: 22017253 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 19-19 021 DATE: March 24, 2022 REMANDED Entitlement to service connection for residuals of traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 2004 to June 2016. In November 2021, the Veteran testified at a Board hearing. The transcript is of record. 1. Entitlement to service connection for residuals of TBI Review of the record identified relevant outstanding service treatment records. A remand is required to allow VA to obtain these records. The Veteran reported that he spent two weeks at a German hospital after his motor vehicle accident where he lost consciousness and was evaluated for memory and brain trauma issues. He also indicated that he may have undergone a TBI evaluation at Fort Drum. Accordingly, a remand is required to allow VA to request these records. The etiology opinion included in the report of the November 2017 VA examination relies, in part, on a lack of hospitalization records from the motor vehicle accident or a TBI evaluation in service. As set out above, attempts must be made to obtain this evidence. An addendum opinion is required to address this evidence. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Obtain any outstanding records pertinent to the Veteran's claims to the extent possible, to include outstanding service treatment records and medical records from the hospital in Germany where he was treated for the claimed motor vehicle accident. Secure the proper authorizations where necessary All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If, after making reasonable efforts, the records cannot be obtained, notify the Veteran and his representative and (a) identify the specific records that cannot be obtained; (b) briefly explain the efforts made to obtain those records; and (c) describe any further action to be taken with respect to the claim. The Veteran must then be given an opportunity to respond. 3. After the above development is completed, return the claims file to the examiner who provided the November 2017 VA opinion. If the November 2017 examiner is not available, the claims file should be provided to an appropriate medical professional for an addendum opinion. The examiner should review the Veteran's claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination, if necessary, the examiner must address the following: Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran has residuals of TBI related to active service or is caused by or aggravated by military service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms. The examiner must specifically consider and discuss the lay statements of record and the opinion and rationale should reflect such consideration. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Finally, readjudicate the appeal. If the service connection sought for residuals of TBI remains denied, issue a supplemental statement of the case and return the case to the Board. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.