Citation Nr: 22028412 Decision Date: 05/13/22 Archive Date: 05/13/22 DOCKET NO. 18-27 330 DATE: May 13, 2022 ORDER The claim of entitlement to service connection for a dental disorder for compensation purposes is dismissed. As new and material evidence has been received since the last prior final disallowance in August 1979, the claim to reopen the issue of entitlement to service connection for residuals of a head injury is granted. Reconsideration under 38 C.F.R. § 3.156(c) of the 2005 and 2009 rating decisions that denied service connection for residuals of head injury is granted REMANDED Entitlement to service connection for residuals of a head injury, to include headaches, balance problems, a back disorder, a neck disorder, and/or a psychiatric disorder, is remanded. FINDINGS OF FACT 1. On February 2, 2022, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant that a withdrawal of the appeal regarding entitlement to service connection for a dental disorder for compensation purposes is requested. 2. An unappealed August 1979 rating decision denied service connection for residuals of a head injury, including head, back, and neck conditions; new and material evidence was not received prior to expiration of the appeal period; subsequently received evidence includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim 3. Service department records from the Veteran's second period of service from October 1979 to October 1983 were in existence at the time of 2005 and 2009 rating decisions that denied service connection for residuals of a head injury, which were not associated with the claims file until 2016; those records were not in existence as the time of the August 1979 rating decision; finality does not attach to the 2005 and 2009 rating decisions, and reconsideration is warranted. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal of the issue of entitlement to service connection for a dental disorder for compensation purposes by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The August 1979 rating decision denying service connection for residuals of a head injury is final; and new and material evidence has been received since the August 1979 prior final disallowance to reopen the claim. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. 3. The criteria for reconsideration under 38 C.F.R. § 3.156(c) of the 2005 and 2009 rating decisions that denied service connection for residuals of head injury are met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(c). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1976 to July 1979 and from October 1979 to October 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2022, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. The Veteran initially filed a claim for residuals of a TBI, including head, neck, and back conditions, but he later clarified that he wished to include a psychiatric disorder, headaches, and balance problems. See VA 21-526b, Veteran Supplemental Claim (June 2012); Congressionals (October 2016); Hearing Transcript (February 2022). Although a Veteran may identify a particular disorder when he or she files a claim, the scope of the claim cannot be limited only to the disorder stated, but must be considered a claim for any disorder that may reasonably be encompassed by several factors including the description of the claim, the symptoms the claimant describes, and the information the claimant submits or that VA obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Where there is not a prior, final decision on one diagnosis based on competent medical evidence that justifies separating a new diagnosis into a separate claim, and the claim is still in the initial adjudicatory phase, the Veteran's statements do not limit the scope of the claim. Clemons, 23 Vet. App. at 5. Here, after the issue of entitlement to service connection is reopened, the issue is characterized to include psychiatric symptoms. Notably, the RO notified the Veteran that the claim on appeal included psychiatric symptoms from the claimed TBI. See Correspondence (July 2016); Correspondence (August 2016). Additional relevant VA and private medical records have been associated with the claims file since the issuance of the statement of the case. See SOC (April 2018); CAPRI (December 20190; CAPRI (January 2020); Medical Treatment Record Non-Government Facility (November 2021); CAPRI (March 2022); Medical Treatment Record (April 2022); C&P Exam (April 2022). However, the private treatment records were submitted by the Veteran and are thus subject to an automatic waiver. See Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 and providing that, in cases where a substantive appeal was received on or after February 2, 2013, there is an automatic waiver of initial RO review if the veteran or his/her representative submits evidence to the RO or the Board; the automatic waiver does not apply to VA-generated evidence). Regarding the VA records, there is no prejudice to the Veteran in proceeding to adjudicate these issues as one is withdrawn and one is granted and remanded. 1. Entitlement to service connection for a dental disorder for compensation purposes is dismissed. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55. In the present case, the appellant, through his/her authorized representative, has withdrawn the issue of entitlement to service connection for a dental disorder for compensation purposes and, hence, there remain no allegations of errors of fact or law for appellate consideration. An oral withdrawal of an appeal, such as one made at a hearing, must be (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action on the part of the claimant. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); Acree v. O'Rourke, 891 F.3d 1009, 1014 (Fed. Cir. 2018) (the Board must address all three prongs of the DeLisio standard when it applies). At the Board hearing, the Veteran affirmed that he wished to withdraw the dental disability claim, and that he understood if the claim was later granted, he would forfeit the current date of claim for compensation purposes. See Hearing Transcript (February 2022). The Veteran stated that he had made that decision in consultation with his attorney. See Hearing Transcript (February 2022). The Board finds this withdrawal to be explicit, unambiguous, and with a full understanding of the consequences. Accordingly, the issue is dismissed. 2. Whether new and material evidence has been submitted to reopen the previously denied claim for service connection for residuals of a head injury. The Veteran contends that he has residuals of a TBI due to two in-service motor vehicle accidents. He has alleged neck pain, back pain, headaches, and psychiatric symptoms. See VA 21-0781, Statement in Support of Claim for PTSD (January 2022); Congressionals (October 2016); VA 21-4138 Statement In Support of Claim (February 2009). In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. Regardless of the action taken by the RO, the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As part of this review, the Board considers evidence of record at the time of the previous final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim, and evidence submitted since a prior final disallowance. Evans v. Brown, 9 Vet. App. 273, 285-86 (1996). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist or consideration of a new theory of entitlement. Shade, 24 Vet. App. at 117-18. Additionally, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Furthermore, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file when VA first decided the claim, VA will reconsider the claim, rather than requiring new and material evidence. 38 C.F.R. § 3.156(c)(1). A claim is not reconsidered, however, where VA could not have obtained the records when it initially decided the claim because the records did not exist at that time, or because the claimant failed to provide sufficient information to identify and obtain the records from the respective service department or any official source. 38 C.F.R. § 3.156(c)(2). To establish service connection, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called nexus requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). An August 1979 rating decision denied service connection for neck, back, and head conditions as residuals of an automobile accident because no chronic disabilities were shown as residuals. See Rating Decision (August 1979). VA notified the Veteran of that decision and how to appeal. VA received no appeal or new and material evidence prior to expiration of the appeal period. The rating decision is final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. December 2005 and June 2009 rating decisions denied the claim for service connection for neck, back, and head conditions as a residual of an automobile accident as new and material evidence had not been received. See Rating Decision (December 2005); Rating Decision (June 2009). VA notified the Veteran of these decisions and how to appeal. VA received no appeal or new and material evidence prior to expiration of the appeal period for either decision. Notwithstanding, the Board finds that finality does not attach to these decisions as service department records from the Veteran's second period of service (October 1979 to October 1983) were in existence at the time of 2005 and 2009 rating decisions although the service records were not associated with the claims file until 2016. 38 C.F.R. § 3.156(c). Indeed, VA is required to reconsider a veteran's claim when relevant service department records are newly associated with a veteran's claims file under § 3.156(c), whether or not the records are new and material under § 3.156(a). In June 2012,VA received the Veteran's claim to reopen, which was denied in a March 2014 rating decision. See VA 21-526b, Veteran Supplemental Claim (June 2012); Rating Decision (March 2015); NOD (April 2015); Form 9 (May 2018). This appeal arises from the Veteran's disagreement with the March 2015 rating decision. The Board concludes that the August 1979 rating decision denying service connection for residuals of a head injury is final; and new and material evidence has been received since the August 1979 prior final disallowance to reopen the claim. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. The Board also concludes that The criteria for reconsideration under 38 C.F.R. § 3.156(c) of the 2005 and 2009 rating decisions that denied service connection for residuals of head injury are met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(c). First, the Board finds that evidence received since the prior final disallowance in August 1979 is new and material. Regarding whether new and material evidence has been submitted since the August 1979 rating decision, evidence of record at that time included STRs from the first period of service which showed an in-service automobile accident in August 1977, with a negative cervical spine x-ray but a prescription for a neck brace. A few days later, the assessment was cervical strain. See STR Medical (August 1979). Over a week later, the assessment was continuation of pain; the neck brace was continued. In a May 1978 STR, the Veteran reported back and neck pain of 17 days due to an auto accident. There was a negative cervical spine x-ray, a laceration of the right eyelid and chin, and a back strain. At service discharge, a report of medical examination was silent for any residuals, except for scars. In a service discharge report of medical history, the Veteran reported a head injury in a 1977 car accident. See STR Medical (August 1979). Also of record was the Veteran's claim alleging treatment in August 1977 for head, neck, and back disorders. See Rating Decision (August 1979); STR Medical (August 1979); VA 21-526 Veterans Application for Compensation or Pension (August 1979). Evidence submitted after the August 1979 decision includes STRs from the second period of service, VA and other medical records, additional lay statements, and VA examinations and opinions. See e.g., STR - Medical (January 2016); Medical Treatment Record Government Facility (January 2003); VA 21-4138 Statement In Support of Claim (June 2005); Medical Treatment Record Government Facility (November 2005); Medical Treatment Record Government Facility (January 2009); Medical Treatment Record Government Facility (May 2009); CAPRI (January 2016); CAPRI (December 2019); CAPRI (April 2022); C&P Exam (January 2018); C&P Exam (July 2017). A Report of Medical History in the newly associated STRs showed the Veteran reported a head injury in a car accident while in Germany. See STR Medical (January 2016). VA examinations and opinions appear to diagnose residuals of a TBI. See C&P Exam (January 2018); C&P Exam (July 2017). The evidence, including the VA examinations and opinions, is new and material because it was not previously considered by VA adjudicators and relates to unestablished facts necessary to establish the claimthat is, evidence of residuals of a TBI due to service. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. The evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance including an examination, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Therefore, the claim is reopened. Second, as indicated above, the Board finds that reconsideration of the 2005 and 2009 rating decisions is warranted under 38 C.F.R. § 3.156(c). In legacy appeals, new and material evidence is generally required to reopen disallowed claims and reconsider the merits. 38 C.F.R. § 3.156(b). However, 38 C.F.R. § 3.156(c) provides an exception to this rule. At any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. 38 C.F.R. § 3.156(c)(1). In contrast to the general rule governing disallowed claims, § 3.156(c) requires the VA to reconsider a veteran's claim when relevant service department records are newly associated with the veteran's claims file, whether or not they are "new and material" under § 3.156(a). See Blubaugh v. McDonald, 773 F.3d 1310, 1313 (Fed. Cir. 2014). Reconsideration under § 3.156(c)(1) requires the VA to reassess its original decision in light of the new service records and may also include the development of additional evidence. See George v. Shulkin, 29 Vet. App. 199, 205 (2018), vacated on other grounds sub nom. George v. Wilkie, 782 F. App'x 997 (Fed. Cir. 2019). It is noted that evidence of record at the time of the August 1979 rating decision included service treatment records (STRs) from the Veteran's first period of service from 1976 to 1979. After the August 1979 rating decision, the Veteran served a second period of active service from October 1979 to October 1983. See Military Personnel Record (January 2016). By at least 2001, the RO was informed that the Veteran had a second period of active service. See VA 10-10 Forms (July 2001). At no point prior to the 2005 and 2009 rating decisions, however, did the RO attempt to obtain STRs for this second period of service; the 2005 and 2009 rating decisions note only the first period of service. See Rating Decision (December 2005); Rating Decision (June 2009). These records were associated with the claims file in 2016 and include a report of medical history from December 1981 in which the Veteran reported a head injury. The STRs also include cervical spine x-rays and complaints of neck and left shoulder pain. See STR Medical (January 2016). The Board finds that reconsideration is warranted as these were relevant official service department records that existed but were not associated with the claims file when VA decided this claim. 38 C.F.R. § 3.156(c)(1). Reconsideration is not warranted, however, as to the 1979 rating decision because it was issued prior to the Veteran's second period of service; thus, the service department records were not in existence at that time. 38 C.F.R. § 3.156(c)(2). REASONS FOR REMAND Entitlement to service connection for residuals of a head injury, to include headaches, balance problems, a back disorder, a neck disorder, and/or a psychiatric disorder, is remanded. The Veteran contends that he has residuals of a TBI due to two in-service motor vehicle accidents. He has alleged neck pain, back pain, headaches, balance problems, and psychiatric symptoms. See VA 21-0781, Statement in Support of Claim for PTSD (January 2022); Congressionals (October 2016); VA 21-4138 Statement In Support of Claim (February 2009); Hearing Transcript (February 2022). The Veteran has also alleged in-service headache symptoms that have continued since that time. See Hearing Transcript (February 2022). The Board finds that remand is warranted to ensure that VA has met its duty to assist. First, remand is necessary to obtain VA treatment records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records. 38 C.F.R. § 3.159(c)(2). At the Board hearing, the Veteran stated that he first sought treatment right after service discharge in the early 1980s at the Atlanta VA Medical Center. The earliest VA treatment records associated with the claims file, however, are dated in 1997. See CAPRI (January 2016). Therefore, these must be obtained on remand. Second, remand is required to obtain an adequate VA examination and opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The medical history is relevant to the determination of the adequacy of the VA opinions. The Veteran's STRs show two in-service car accidents. In an August 17, 1977, record, the Veteran reported he was in an auto accident and complained of a sore neck. A cervical spine x-ray was negative. A neck brace was prescribed. Two days later, the Veteran reported neck pain and headaches. The assessment was cervical strain. The cervical collar was continued. In an April 30, 1978, STR, the Veteran reported a car accident the day before. The Veteran reported neck pain, shoulder pain, and there were lacerations of the left eye. He was referred to the orthopedic outpatient clinic. The impression was face lacerations and back strain. On May 1, 1978, the Veteran reported neck, back, shoulder and chest pain after a head on collision. It was noted that he was fully checked at Landstuhl but was now stiff and painful. On May 17, 1978, the Veteran reported neck and back pain for 17 days after an auto accident. See STR Medical (August 1979). In the June 1979 service discharge report of medical history, the Veteran reported a 1977 car accident with trauma to the left temporal region and that he lost consciousness for one hour. The corresponding report of medical examination noted a normal clinical evaluation of the head. See STR Medical (August 1979). In an initial 2012 VA TBI consultation, the Veteran reported an in-service MVA and a TBI. See CAPRI (January 2016). In the history section, it was noted the Veteran was hospitalized for one week and then returned to his unit. This is not documented in the STRs; for example, after the 1977 accident a cervical collar was prescribed, but there is no evidence of hospitalization. After the 1978 accident, the Veteran was seen at Landstuhl. A day later, he was seen at the base outpatient clinic and there was no mention of hospitalization. See STR Medical (August 1979). After examination and diagnostic testing, the VA clinician found that the Veteran exhibited intact cognitive functioning with mild impairment in speed of information processing and more moderate impairment in verbal recognition, memory, and visual-spatial orientation. The examiner opined that it was unlikely that these impairments are a direct result of his TBI, given the length of time since the injury, the recency and relatively mild level of cognitive impairment, and due to the recent imaging, are more likely a reflection of normal aging. See CAPRI (January 2016). In a May 2015 TBI Questionnaire, a VA clinician reviewed the Veteran's STRs and diagnosed late effects of TBI with impaired memory and executive function, headaches, and generalized anxiety disorder. See Medical Treatment Record Government Facility (May 2015). The clinician opined that the current diagnoses are attributed to the documented head injury sustained in a car accident, reasoning that the headaches suffered by the Veteran on the fifth day after the car accident are consistent with TBI patients that they have treated, that the STRs show trauma to the left temporal region of his head and that he lost consciousness for one hour, and that at an initial 2012 TBI evaluation there was history of head injury with loss of consciousness and post-traumatic amnesia, consistent with at least a mild traumatic brain injury. See Medical Treatment Record Government Facility (May 2015). However, the STRs do not show that the Veteran lost consciousness for one hour - this was merely the Veteran's assertion on the service discharge report of medical history. See STR Medical (August 1979). The STRs also do not document post-traumatic amnesia. See STR Medical (August 1979). Furthermore, the examiner did not address the 2012 TBI clinician's assessment. Hence, the absence of a meaningful discussion of the relevant documented and reliance in part on inaccurate facts casts doubt on the medical opinions' foundation and, accordingly, the Board finds the opinion inadequate to decide the claim. In a May 2016 submission from a private social worker, the clinician noted a diagnosis of TBI resulting from a history of TBI, including a motor vehicle accident in Germany, which has caused symptoms. See Medical Treatment Record -Non-Government Facility (June 2016). Accordingly, the Board does not assign this opinion any significant value as it is not accompanied by any actual supporting explanation for the opinion that there was a TBI during active service. In a July 2017 VA headaches examination, conducted without review of relevant records, the Veteran alleged onset of headaches in 1977 after an in-service motor vehicle accident. The examiner diagnosed tension headaches. See C&P Exam (July 2017). No opinion was provided. A July 2017 VA TBI examination was conducted upon review of VA treatment records and STRs. The examiner diagnosed TBI, noting the condition began after in-service car accidents. The Veteran reported his current symptoms as headaches, insomnia, hearing loss, ringing in the ears, depression, anxiety, irritability, trouble concentrating, and memory problems. No diagnostic testing was conducted, including neuropsychological, MRI, computed tomography, EEG, or any laboratory testing. See C&P Exam (July 2017). The examiner did not address the relevant STRs, the 2015 opinion, or the 2012 VA clinician findings. Thus, the Board finds that evidence is inadequate to decide the appeal. A July 2017 VA PTSD examination was conducted upon review of the claims file. The diagnosis was bipolar and related disorder. See C&P Exam (July 2017). The examiner provided no etiological opinion. In a January 2018 addendum opinion, a VA examiner opined that the Veteran's bipolar disorder is at least as likely as not due to his TBI, based upon the July 2017 VA examinations and a review of medical records. See C&P Exam (January 2018). An April 2022 VA medical opinion was that the Veteran's mood disorder was due to service, reasoning that the Veteran had no psychiatric symptoms prior to service. The examiner noted review of the STRs, the July 2017 VA examination that diagnosed TBI, other medical evidence, and the Veteran's lay evidence of experiences and symptoms during service. See C&P Exam (April 2022). The stressors were noted to be the 1978 car accident in which he went through a windshield and hit a wall. See C&P Exam (April 2022). These opinions relied on findings of earlier VA clinicians which the Board has found to be inadequately supported. Thus, these opinions are inadequate to decide the appeal. Given the above discussion, the Board finds that remand is required to obtain an adequate and thorough diagnosis and etiology opinion. Remand is required for a determination of whether the in-service motor vehicle accidents caused a TBI and if so, whether there are residuals, to include headaches, a neck disorder, a back disorder, and/or a psychiatric disorder; the examiner must address all relevant evidence of record. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from October 1983 to 1998. 2. Schedule the Veteran for a VA examination(s) to address the presence and etiology of the Veteran's claimed TBI. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record and interview of the Veteran, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with a TBI. The opinion should, among other things, include a discussion of the Veteran's documented history and assertions. The opinion 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). The clinician should provide the following opinions, with supporting rationale on: a) Whether there is a diagnosis of cervical spine degenerative joint disease or degenerative disc disease during active service. Address January 1980 and January 1981 STRs, including radiographic reports. b) Whether there is a diagnosis of a TBI that at least as likely as not (1) had its onset in service, or (2) is otherwise related to an in-service injury, event, or disease, to include the two in-service motor vehicle accidents in 1977 and 1978. Consider all relevant history and medical findings to include the following STRs: (1) August 1977 STRs showing Veteran's report of that he was involved in an auto accident and had sore neck; and that he was assessed with cervical strain (given cervical collar); (2) April 1978 STR showing that the Veteran was in car accident a day earlier, was seen the past night, but still has residual pain in neck and shoulders; (3) an April 1978 STR showing auto accident and pain of the left shoulder/scapula pain and cervical region, but with negative cervical spine x-ray and findings for laceration of left eyelid and chin and back strain; (4) a May 1978 STR showing history of auto accident in May 1978 with neck and back pain for past 17 days, right side; (5) a May 1978 STR showing complaints of pain of neck, back, shoulders, and chestwith notation head on collision along with very stiff and painful; (6) a June 1979 Report of Medical Examination (ROME) at separation reflects normal clinical evaluation of all systems except for scars; and associated Report of Medical History (ROMH) showing that the Veteran denied periods of unconsciousness although he gave a history of head injury and car accident in June 1977; (7) January 1980 STR showing narrowed joint space C6-C7 - posterior spurs; (8) January 1981 STR showing imaging findings for the cervical spine; (9) a December 1981 ROMH showing history of head injury, headaches and that the Veteran denied a history of depression, nervous trouble, recurrent back pain, and foot troublewith examiner's explanation of head injury with loss of consciousness 3 years prior; (10) December 1981 ROME showing normal clinical evaluation for head, feet, psychiatric systems; (11) May 1982 STR noting auto accident 2 hours ago. c) If there is a diagnosed in-service TBI, provide opinions and appropriate examinations for all residuals, to potentially include headaches, a neck disorder, a back disorder, and a psychiatric disorder. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If any medical history is rejected, a complete explanation is required. 3. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.M., 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.