Citation Nr: 22028992 Decision Date: 05/17/22 Archive Date: 05/17/22 DOCKET NO. 19-22 275A DATE: May 17, 2022 ORDER Entitlement to a 100 percent disability rating for traumatic brain injury (TBI) residuals is granted throughout the period of the claim. REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance by another person is remanded. FINDING OF FACT The evidence is in approximate balance as to whether the Veteran's TBI residuals have manifested as objective evidence on testing of severe impairment of memory resulting in severe functional impairment throughout the period of the claim. CONCLUSION OF LAW Throughout the period of the claim the criteria for a maximum 100 percent disability rating for the Veteran's residuals of TBI have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.124a, Diagnostic Code (DC) 8045. REASONS AND BASES FOR FINDING AND CONCLUSION Introduction The Veteran served on active duty in the United States Navy from September 2006 to July 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued by the U.S. Department of Veterans Affairs (VA) Regional Office (RO). In an April 2020 decision, the Board denied the Veteran's claims. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court), and in a February 2021 Order, the Court granted a Joint Motion for Remand (JMR) filed by the parties (VA and the Veteran), vacating the Board's decision and remanding the claims. In May 2021, the Board remanded this case for additional development consistent with the terms of the JMR. The case has now been returned to the Board for further appellate review. When a Veteran files a claim for an increased rating, he or she is presumed to be seeking the maximum benefit under any applicable theory. See Rice v. Shinseki, 22 Vet. App. 447, 45354 (2009). In light of this principle, entitlement to special monthly compensation (SMC) has been found to be an inferable issue anytime a veteran is requesting increased benefits. Akles v. Derwinski, 1 Vet. App. 118 (1991). The Veteran has contended he is entitled to SMC based on the need for aid and attendance by another person due to his service-connected disabilities. As such, the Board will infer the issue of entitlement to SMC at this time. General Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. "[I]f the positive and negative evidence is in approximate balance ... the claimant receives the benefit of the doubt." Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Background and Analysis Residuals of a TBI are rated under 38 C.F.R. § 4.124a, DC 8045. Under DC 8045, there are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, are evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Emotional/behavioral dysfunction are evaluated under § 4.130 (Schedule of ratings - mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Physical (including neurological) dysfunction is evaluated based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. Residuals not listed here that are reported on an examination, are evaluated under the most appropriate diagnostic code. Each condition is evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The need for special monthly compensation should be considered for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, and labeled "total." However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100-percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. DC 8045 includes five notes: Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" traumatic brain injury, which may appear in medical records, refer to a classification of traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. The Board has reviewed all of the evidence of record, with an emphasis on the evidence relevant to the Veteran's claim. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's claim. November 2014 VA outpatient records show the Veteran was extensively evaluated by a VA psychiatrist. The Veteran was noted to have little memory of his military service and fragmented memories of life prior to the Navy. The Veteran further reported significant anger leading to violent encounters and legal involvement but little recall of the particular events. The Veteran's wife asserted that the Veteran had periods of staring into space for a few minutes, and that he appeared to have "blackouts," such as getting lost while driving and forgetting other things. She asserted that these changes occurred after the Veteran's active service. The Veteran was administered the Saint Louis University Mental Status (SLUMS) examination. Ultimately, the VA psychiatrist stated that although the Veteran appeared healthy, he had a severe memory impairment and low scoring SLUMS. The psychiatrist stated that one could surmise from the lack of documented post-service treatment, one of three possibilities: the Veteran was exaggerating symptoms; the Veteran had significant post-TBI deficits that were apparent only on close interview; and/or there had been a rapid decline in the Veteran's mental state. Based on his examination and interview, the psychiatrist stated that he suspected the second possibility, that the Veteran had significant post-TBI deficits. The Veteran was also evaluated by a VA clinical neuropsychologist in November 2014. In short, the neuropsychologist noted significant mental health symptoms and complaints of memory loss, but determined that the severity of these symptoms was inconsistent with the Veteran's remote history of a TBI. The Veteran was afforded a VA TBI examination in December 2014. The examination report indicates normal findings with respect to all TBI facets. The Board observes, however, that the JMR referenced above determined that the December 2014 VA examination was "inadequate for adjudication" as it was inconsistent with continuous reports of memory loss throughout the claim period. Under these circumstances, the Board finds the December 2014 report is of negligible probative value. The Veteran was afforded an additional VA TBI examination in January 2018. Upon examination, the VA examiner indicated the Veteran had objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. In this regard, the examiner noted the Veteran's report that he had to rely on notes to recall things. The examiner further noted the Veteran had moderately impaired judgment, and that his social interaction was frequently inappropriate, having been fired from his job due to anger issues. Orientation and motor activity were noted to be normal. Visual spatial orientation was noted to be mildly impaired, as the Veteran reported he occasionally got lost in unfamiliar surroundings and had difficulty reading maps. The examiner indicated the Veteran had three or more subjective symptoms that mildly interfered with work, specifically headaches, insomnia, and hypersensitivity to light and sound. The Veteran was noted to have one or more neurobehavioral effects that interfered with or precluded workplace interaction, social interaction, or both on most days or that occasionally required supervision for safety of self or others. Specifically, the Veteran reported irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, and inflexibility, which had made employment difficult. Communication and consciousness were noted to be normal. The examiner further indicated the Veteran had headaches attributable to his TBI. In a December 2018 statements, the Veteran's friends, D.B. and A.V., and the Veteran's mother, described the Veteran's symptoms as including an inability to remember events from his life or other details without writing them down, anger, anxiety attacks, mood changes, social isolation, and impaired impulse control. In February 2019, a statement was submitted by D.R., a friend of the Veteran and a psychiatric nursing student. D.R. cited research for the proposition that where TBI and psychiatric symptoms overlapped, symptom trajectory could not be reliably predicted, and asserted that VA examiners' characterization of the Veteran's TBI as mild were an oversimplification and unsupported by the record, to include evidence of rapid personality changes in the Veteran. D.R. went on to detail the Veteran's symptoms she had witnessed, to include unpredictable and maladaptive behavior, reduced impulse control and emotion regulation, anger, sleep deprivation, and memory loss. The Veteran was afforded an additional VA TBI examination in May 2019. Upon examination, the examiner noted a complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing. The examiner noted judgment was normal, but that social interaction was occasionally inappropriate. Orientation and motor activity were indicated as normal. Mildly impaired visual spatial orientation was noted. Specifically, the Veteran was noted to occasionally get lost in unfamiliar surroundings and have difficulty reading maps or following directions. The examiner indicated the Veteran had three or more subjective symptoms that mildly interfered with work, instrumental activities of daily living, or relationships. Specifically, the Veteran's anxiety and depression were noted to prevent him from doing anything with his children. The Veteran was noted to have one or more neurobehavioral effects that frequently interfered with workplace interaction, social interaction, or both but did not preclude them. Specifically, irritability, lack of motivation, verbal aggression, belligerence, and moodiness were noted. The Veteran was noted to be able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language, and consciousness was normal. In October 2019, a VA psychologist opined that the Veteran's reported history of TBI would not likely account for his suspect performance on objective measures of test engagement, which are commonly passed even in the cases of more severe head injuries and mild dementia. In a May 2021 statement, the Veteran's friend reiterated the severity of the Veteran's symptoms, and asserted that he required being checked on several times per day. The Veteran was afforded an additional VA TBI examination in September 2021. Upon examination, the VA examiner indicated the Veteran had objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. The examiner indicated the Veteran had moderately severely impaired judgment due to impaired memory, impulsivity, and irritability. Social interaction was noted to be inappropriate most of the time, to include constant confrontations and being thrown out of establishments. Orientation and motor activity was normal. Visual spatial orientation was mildly impaired. The examiner indicated the Veteran had three or more subjective symptoms that mildly interfered with work, instrumental activities of daily living, or relationships. Specifically, the Veteran had significant headaches, irritability, and impaired decision making, memory, and social interaction skills. The Veteran was noted to have one or more neurobehavioral effects that frequently interfered with workplace interaction, social interaction, or both but did not preclude them. Specifically, the Veteran was noted to constantly argue, fight, and disagree with others and have frequent confrontations. With regard to functional impairment, the examiner stated that due to poor ability to function socially (severe irritability, frequent arguments/fights), poor ability to remember and process/follow through with simple tasks, the Veteran was unable to function in a work environment. The September 2021 VA examiner noted that previous examiners varied in their opinions regarding the etiology of the Veteran's cognitive deficits (ranging from TBI residuals to malingering to too many confounding factors to assess). The examiner stated that of note, there was marked consistency in the performance of the Veteran in marked deficits in specific domains identified by the different examiners in between their examinations. This relative consistency, the examiner explained, would not be expected in a patient attempting to falsify results, especially when administered years apart. The examiner asserted that it was unlikely that the mild decline in testing over the years would be attributable to a TBI, as cognition generally improves or remains stable over time post-TBI. Instead, he stated, it was more likely that ongoing deterioration of cognitive status or deterioration of symptoms is related to superimposed psychiatric comorbidities. The examiner further stated it was "difficult to agree" with the 2019 neuropsychologist assessment referenced above, that the severity of the Veteran's cognitive deficits was excessive compared to the degree of TBI, due to the fact that there was relatively little medical information in the record regarding the Veteran's immediate post-TBI course that would allow us to accurately determine the true severity of his TBI. In this regard, the examiner noted that many patients with moderate to severe TBIs have normal braining imaging and no major sensorimotor deficits, but do have significant cognitive and executive function deficits that would not warrant prolonged hospitalization but certainly could be extremely destructive to post-TBI function. The examiner concluded that for these reasons, it was as likely as not that the Veteran's symptoms were residuals of his TBI. The examiner ended by noting that the Veteran's TBI symptoms were likely to create significant difficulty for his coping with fluctuations in his personal, emotional, and psychiatric state. The Board has carefully reviewed the foregoing, and the entire record, including voluminous VA outpatient treatment records. The Board initially notes that there is significant disagreement among VA providers as to whether the Veteran's symptomatology is attributable to his TBI, and if so, which symptoms. The range of opinions is well-summarized by the September 2021 VA examiner, as spanning from full attribution to the TBI, malingering, or a combination of the TBI and psychiatric and other causes. In this regard, the Board notes that the Veteran's psychiatric condition has been service-connected. The Board notes that the most prominent examples of findings that the Veteran's symptoms were not attributable to his TBI, and/or were too severe to be consistent with a "mild" TBI, are the November 2014 assessment and the October 2019 opinion summarized above. The Board observes that the November 2014 and October 2019 opinions were authored by a neuropsychologist and psychologist, respectively, neither of which are specialists designated by VA to perform initial assessments of TBIs. The Board further observes that neither of these VA providers provided any assessment as to what, if any, of the Veteran's symptoms was attributable to his service-connected psychiatric conditions, which are service connected on the basis that they are secondary to his TBI. Furthermore, the Board notes that each opinion was based on an understanding of the Veteran's in-service TBI as being "mild." As noted by the September 2021 examiner, however, there is little evidence of record by way of detailed description of the Veteran's immediate post-TBI treatment or other course. In this regard, the September 2021 examiner, a VA psychiatrist, explained in detail that although certain TBIs do not cause symptoms requiring prolonged hospitalization and do not result in abnormal imaging, other symptoms (not requiring immediate treatment) impacting cognition and executive functions may be present and cause significantly destructive impairment post-TBI. The Board observes that such a course following the Veteran's TBI is supported by numerous statements submitted by the Veteran, friends, and family, attesting to stark personality and other changes between pre- and post-service. Finally, the Board observes that in addition to the November 2014 psychiatrist and September 2021 examiner, VA examiners in January 2018 and May 2019 attributed the Veteran's symptoms to his TBI and/or psychiatric conditions. After careful assessment of the foregoing, the Board acknowledges the significant confusion among VA providers as to the nature and severity of the Veteran's symptoms. On the one hand, two VA providers who are not TBI specialists pursuant to VA policy have indicated the Veteran's symptoms are not attributable to his TBI. On the other hand, four VA examiners have indicated that the symptoms likely are attributable to the Veteran's TBI and/or comorbid psychiatric symptomatology. The Board again observes that service connection for a major depressive disorder, anxiety disorder, has been granted. Under the foregoing circumstances, the Board finds that the evidence is in at least approximate balance as to whether the Veteran's symptomatology is fully attributable to his service-connected TBI and psychiatric conditions. Regarding the severity of the Veteran's condition, the Board notes that upon extensive examination and interview, to include objective SLUMS testing, a VA psychiatrist in November 2014 concluded that the Veteran appeared healthy, but had a severe memory impairment which became apparent on close interview. The January 2018 examination reports includes an indication of moderate memory impairment. The May 2019 examination report includes an indication of mild memory impairment. The September 2021 examination report includes an indication of moderate memory impairment. In summary of the numerous statements submitted by the Veteran and his friends and family members, the statements attest to an inability to remember events from the Veteran's life, frequently becoming lost, and forgetting details unless they are written down. At this juncture, the Board notes that the words "mild," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Upon review of the foregoing, it is clear that the severity of the Veteran's memory impairment may have fluctuated during the period of the claim. It is also apparent that even highly trained VA psychiatrists may differ as to their assessment of the severity of memory loss. In the end, the Board's duty is to carefully review the entirety of the evidence and to resolve any reasonable doubt with respect to material issues in favor of the Veteran. In this regard, the Board observes that the evidence does not suggest a fundamental change in the severity of the Veteran's reported memory loss or other symptoms throughout the appeal period. As such, the Board is left with four assessments by VA specialists as to the severity of the Veteran's memory loss, including the November 2014 assessment by a VA psychiatrist, following extensive evaluation and interview, that the Veteran's memory loss was severe. Accordingly, the Board has resolved reasonable doubt amongst the various evaluations of record in favor of the Veteran, and has determined that the entirety of the evidence of record is in approximate balance as to whether the Veteran's TBI residuals have manifested throughout the claim period as objective evidence on testing of severe impairment of memory resulting in severe functional impairment. With regard to functional impairment, the Board observes that VA has previously granted entitlement to a total disability rating based on individual unemployability, which recognizes the Veteran's inability to maintain employment due to his service-connected disabilities, most prominently his TBI, since March 2015. In concluding, the Board notes that objective evidence on testing of severe impairment of memory resulting in severe functional impairment correlates to a "total" level of evaluation under memory facet of the Rating Schedule's table entitled "Evaluation of Cognitive Impairments and Other Residuals of TBI Not Otherwise Classified." In turn, a 100 percent rating is assigned where "total" is the evaluation for one or more facets. Accordingly, granting of a 100 percent rating throughout the claim period is warranted. Because the Board has determined that a maximum 100 percent rating is warranted for a total evaluation under the "memory, attention, concentration, executive functions," it need not extensively discuss the Veteran's symptomatology significantly impairing his social interaction, spatial orientation, subjective symptoms, neurobehavioral effects, and communication, though the significant symptomatology in these areas is touched on above. REASONS FOR REMAND The Board finds that additional development is required before the Veteran's remaining claims are decided. Service connection for PTSD In a November 2021 rating decision, the RO granted service connection for major depressive disorder and unspecified anxiety disorder. The decision was based on an August 2021 VA medical opinion to the effect that the Veteran's major depressive disorder and anxiety disorder had been aggravated by his service-connected TBI. The RO, however, has continued to deny entitlement to service connection for PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. The record contains contradictory evidence as to whether the Veteran has been diagnosed with PTSD. In this regard, the Board notes that service connection requires a present disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Specifically, VA psychiatric examination reports completed in August 2021 and November 2021 included specific findings that the Veteran did not meet the criteria for a PTSD diagnosis. On the other hand, a November 2018 VA mental health screening was positive for PTSD. In addition, pursuant to a neuropsychological evaluation in May 2019 in the Veteran's outpatient VA records, it was noted the Veteran's self-reported symptoms met the screening criteria for PTSD. Notably, the Board observes that the August 2021 and November 2021 VA examiners did not address the November 2018 and May 2019 indications of PTSD noted above. The Veteran has contended his PTSD is related to the 2008 fall and loss of consciousness during service that is the basis for his service-connected TBI residuals. Under these circumstances, the Board finds that a remand is warranted for an additional VA examination to clarify whether the Veteran has PTSD, and if so, whether it is related to an in-service stressor sufficient to support the diagnosis. Entitlement to SMC The Veteran has contended that his service-connected disabilities, primarily his TBI residuals, require aid and attendance of another person. See 38 C.F.R. § 3.350(b). The evidence is somewhat inconsistent as to whether aid and attendance is required. For example, pursuant to a February 2019 VA psychiatric examination, it was noted that the Veteran was raising his children as a single parent and that everything was "good" in that regard. He reported doing the chores, housework, errands, shopping, taking his children to appointments, and paying all the bills, and having no problems in these areas. On the other hand, in a May 2021 statement, the Veteran's friend asserted that the Veteran required being checked in on several times a day, and needed assistance with grocery shopping and other activities. Based on the contradictory evidence of record, the Board finds that a remand is warranted for a VA medical examination to assess the Veteran's eligibility for SMC based on the need for aid and attendance. The matters are REMANDED for the following actions: 1. Afford the Veteran a VA examination to clarify whether he has PTSD. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should confirm or rule out PTSD. If the examiner determines the Veteran has not had PTSD during the period of the claim, he or she should provide a full medical explanation for his or her finding. If the examiner finds the Veteran has had PTSD during the period of the claim, he or she should state an opinion as to the following: (a) Is the evidence in at least approximate balance as to whether the Veteran's PTSD was incurred in or is otherwise causally related to his active service? In providing his or her opinions, the examiner should address the following evidence: (i) A positive screening for PTSD in November 2018 (VA outpatient records); (ii) A May 2019 neuropsychological evaluation report stating the Veteran's "symptom endorsements on the PCL-5 (score=50) met DSM-5 screening criteria for PTSD" (VA outpatient records); and (iii) The Veteran's contention that his PTSD is secondary to the 2008 fall and loss of consciousness which is the basis for his service-connected traumatic brain injury (TBI) residuals. The examiner must provide a rationale for any proffered opinion. 2. Afford the Veteran a VA examination to determine whether the Veteran requires the regular aid and attendance of another solely due to his service-connected disabilities. Following the examination and a review of the relevant records and lay statements, the examiner should state whether the Veteran's service-connected disabilities (TBI residuals, acquired psychiatric disorder, migraine headaches, lumbar spine degenerative arthritis, left knee disability, right knee disability, right hip disability, and tinnitus), together, are severe enough to require the regular aid and attendance of another person to assist with activities of daily living, such as dressing and undressing, keeping himself ordinarily clean and presentable, feeding, attending to the wants of nature, frequently adjusting any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid, or protecting himself from the hazards or dangers incident to his daily environment. The examiner should review and address all relevant VA examination reports as well as VA and private treatment records. (Continued on the next page) In providing his or her opinion, the examiner should not consider the impact of non-service-connected disabilities. The examiner must provide a rationale for any proffered opinion. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Hampton, 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.