TRAUMATIC BRAIN INJURY

D. SMART · 2026 · Case ID: A26035267

MIXED

Summary

The Veteran, a Navy Veteran who served from June 1984 to June 1994, appeals the denial of service connection for right elbow pain, left elbow pain, and a left elbow scar, and the remand of claims for a cervical spine/neck condition and an increased rating for PTSD. The Board granted service connection for Traumatic Brain Injury (TBI), right knee strain, left knee strain, left hip osteoarthritis, and right elbow scar. Service connection was denied for right elbow pain, left elbow pain, and left elbow scar. The Board found the Veteran's TBI, right knee strain, and left knee strain to be related to service, resolving doubt in the Veteran's favor due to the balance of evidence, which included lay statements and a private medical opinion from Dr. J.M. The left hip osteoarthritis was granted on a secondary basis, linked to the service-connected knee and back conditions, supported by Dr. J.M.'s opinion. The denials for elbow conditions were based on a lack of current diagnosis or functional impairment, with the Board giving more weight to VA examinations over a private opinion that lacked specific rationale. The right elbow scar was granted on aggravation of a pre-existing condition, as the presumption of aggravation was not rebutted by clear and unmistakable evidence. The cervical spine/neck condition was remanded for a new medical opinion due to inadequate duty to assist. The PTSD increased rating claim was remanded because its evaluation is intertwined with the newly granted TBI claim, requiring reassessment to avoid pyramiding.

Rationale

Lay statements from Veteran and fellow servicemember corroborate in-service head injuries.; Service treatment records lack documentation of head injuries.; Evidence in approximate balance; doubt resolved in Veteran's favor.; Private opinion from Dr. J.M. found TBI symptoms consistent with sequelae and at least as likely as not related to service.; VA examiner opinion was negative, relying on lack of documentation.

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250507-542976

Full Decision Text

Citation Nr: A26035267
Decision Date: 04/15/26 Archive Date: 04/15/26

DOCKET NO. 250507-542976
DATE: April 15, 2026

ORDER

Service connection for traumatic brain injury (TBI) is granted.

Service connection for right knee strain is granted.

Service connection for left knee strain is granted.

Service connection for left hip osteoarthritis is granted.

Service connection for right elbow pain is denied.

Service connection for left elbow pain is denied.

Service connection for left elbow scar is denied.

Service connection for right elbow scar is granted.

REMANDED

Service connection for cervical spine/neck condition is remanded.

Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to November 21, 2022, is remanded.

FINDINGS OF FACT

1. Resolving doubt in the Veteran's favor, the Veteran's TBI is related to service.

2. Resolving doubt in the Veteran's favor, the Veteran's right knee strain is related to service.

3. Resolving doubt in the Veteran's favor, the Veteran's left knee strain is related to service.

4. Resolving doubt in the Veteran's favor, the Veteran's left hip osteoarthritis is related to his service-connected disabilities of the lumbar spine and knees.

5. The evidence is persuasively against finding functional impairment of earning capacity due to right elbow pain recent to or during the pendency of the claim.

6. The evidence is persuasively against finding functional impairment of earning capacity due to left elbow pain recent to or during the pendency of the claim.

7. The evidence is persuasively against finding a present disability of left elbow scar recent to or during the pendency of this claim.

8. The Veteran has presented evidence that his right elbow scar, which preexisted service, increased in severity during service, and there is no clear and unmistakable evidence that no increase occurred or that any such increase was due to the natural progression of the disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for TBI have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for right knee strain have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for service connection for left knee strain have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for left hip osteoarthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria for service connection for right elbow pain have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

6. The criteria for service connection for left elbow pain have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

7. The criteria for service connection for left elbow scar have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

8. The criteria for service-connected aggravation of right elbow scar have been met. 38 U.S.C. §§ 1110, 1111, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304(b), 3.306.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service in the Navy from June 1984 to June 1994.

The claims for service connection come before the Board of Veterans' Appeals (Board) from a July 2024 decision by the agency of original jurisdiction (AOJ).

In April 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an April 2024 decision. In July 2024, the AOJ issued the HLR decision on appeal, which considered the evidence of record at the time of the prior
.303, 3.304(b), 3.306.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service in the Navy from June 1984 to June 1994.

The claims for service connection come before the Board of Veterans' Appeals (Board) from a July 2024 decision by the agency of original jurisdiction (AOJ).

In the May 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, as to these issues, the Board may only consider the evidence of record at the time of the April 2024 AOJ decision, which was subsequently subject to higher-level review. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, which was subsequently subject to higher-level review, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

The increased rating claim comes before the Board of Veterans' Appeals (Board) from a March 2025 decision by the AOJ.

In November 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a November 2023 decision. In March 2025, the AOJ issued the HLR decision on appeal, which considered the evidence of record at the time of the prior November 2023 decision. Therefore, as to this issue, the Board may only consider the evidence of record at the time of the November 2023 decision.

In the May 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, as to this issue, the Board may only consider the evidence of record at the time of the November 2023 AOJ decision, which was subsequently subject to higher-level review. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, which was subsequently subject to higher-level review, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims for service connection for cervical spine/neck condition and entitlement to an initial evaluation in excess of 50 percent for PTSD prior to November 21, 2022, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Generally, service connection requires: (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. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Alternately, service connection may be granted on a secondary basis given (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310(a), (b).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits.
1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay testimony is competent to prove that a claimant exhibited certain lay-observable symptoms and the time that those symptoms appeared. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).

In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the appellant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776, 777-79 (Fed. Cir. 2021).

1. Service connection for TBI

The Veteran asserts entitlement to service connection for TBI, contending that this disability is due to repeated head injuries sustained during active service. For the following reasons, service connection is granted.

The first element of service connection is met. November 2021 and August 2023 VA examiners diagnosed a TBI.

For the second element, an in-service event, injury, or disease, there is evidence both for and against the claim.

In favor of the claim are lay statements from the Veteran and from fellow servicemember B.F. that, during service, the Veteran sustained head injuries from hatches, doors, or falling objects on more than one occasion during service, resulting in unconsciousness or bleeding. These statements are competent, credible, and consistent with the manner and circumstances of the Veteran's service.

Against the claim is the absence of any documentation in service treatment records of such injuries. The Veteran has acknowledged that his head injuries were not documented but has asserted that he was given pain relievers and returned to duty.

The evidence is thus in at least approximate balance as to whether an in-service event, injury, or disease occurred. Resolving doubt in the Veteran's favor, the second element of service connection is established. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F.4th at 777-79.

As to the third element, nexus, there is evidence both for and against the claim.

In favor of the claim is a September 2023 opinion from physician Dr. J.M. On review of the record, Dr. J.M. opined that the injuries reported by the Veteran were common in sailors and that the symptoms reported by the Veteran, including headaches, depression, anxiety, and cognitive decline, were consistent with TBI sequelae. Dr. J.M. thus opined that the Veteran's TBI was at least as likely as not related to service.

Against the claim is a November 2021 VA examiner's opinion that the Veteran's TBI was less likely than not due to service. The examiner relied on the absence of documentation of a TBI or symptoms thereof during service, with the Veteran not reporting a head injury in Reports of Medical History in 1989 or 1993.

The evidence is thus in at least approximate balance as to whether the Veteran's TBI is related to service. Resolving doubt in the Veteran's favor, a nexus is established. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F.4th at 777-79.

as likely as not related to service.

As the elements of service connection for TBI are met, service connection is granted.

2. Service connection for right knee strain

3. Service connection for left knee strain

The Veteran asserts entitlement to service connection for right knee strain and left knee strain, which he asserts are due to hitting or injuring his knees in service. For the following reasons, service connection is granted.

The first element of service connection is met. A December 2023 VA examiner diagnosed bilateral knee strain.

As to the second element, an in-service event, injury, or disease, there is evidence for and against the claim.

In favor of the claim are lay statements from the Veteran that he struck his knees multiple times while serving aboard a submarine. These statements are competent, credible, and consistent with the manner and circumstances of the Veteran's service.

Against the claim is the absence of any documentation in service treatment records of such injuries.

The third element, a nexus, is met. In September 2023, Dr. J.M. reviewed the record and opined that the Veteran's bilateral knee pain was at least as likely as not related to service. Dr. J.M. explained that repetitive injuries to the knee can contribute to degenerative changes, leading to chronic pain.

This opinion merits significant probative weight, as it is grounded in review of the file and medical knowledge about the etiology of the Veteran's knee disabilities. Moreover, no competent medical source has offered a contrary opinion.

As the elements of service connection for right knee strain and left knee strain are met, service connection is granted.

4. Service connection for left hip osteoarthritis

The Veteran asserts entitlement to service connection for left hip osteoarthritis, contending (as relevant here) that this disability was caused by his service-connected disabilities of the lumbar spine and knees. For the following reasons, service connection on a secondary basis is granted.

The first element of secondary service connection is met. A December 2023 VA examiner diagnosed left hip osteoarthritis.

The second element of secondary service connection is also met. The Veteran is service connected for bilateral knee strain (as explained above) and for degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome, and intervertebral disc syndrome of the lumbar spine.

The third element of secondary service connection is also met. In September 2023, Dr. J.M. reviewed the medical record and explained that pain in the knees and back could impact gait, leading to increased stress on the hips. Dr. J.M. thus opined that the Veteran's left hip pain was at least as likely as not related to service.

This opinion merits significant probative weight, as it is grounded in review of the file and medical knowledge about the etiology of the Veteran's left hip disability. Moreover, no competent medical source has offered a contrary opinion regarding secondary service connection.

As the elements of secondary service connection for left hip osteoarthritis are met, service connection is granted.

5. Service connection for right elbow pain

6. Service connection for left elbow pain

7. Service connection for left elbow scar

The Veteran asserts entitlement to service connection for right elbow pain, left elbow pain, and a left elbow scar, contending that these disabilities are related to his (non-service connected) cervical spine/neck disability.

Unfortunately, the Veteran's claim must be denied, because the Veteran did not have a current right elbow disability, left elbow disability, or left elbow scar at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007
for left elbow pain

7. Service connection for left elbow scar

Regarding the Veteran's claimed right elbow disability, left elbow disability, and left elbow scar, there is no evidence of record of functional impairment of earning capacity from such a disability. Service treatment records do not document complaints of or treatment for these disabilities in service, and post-service treatment records do not contain any documentation of these disabilities. Thus, the evidence is persuasively against finding a present right elbow disability, left elbow disability, or left elbow scar.

The Board acknowledges that Dr. J.M. opined in September 2023 that the Veteran had elbow pain that was related to service. However, this opinion merits no probative weight. Although Dr. J.M. explained that repetitive injuries could cause the Veteran's elbow condition, Dr. J.M. did not provide any rationale for concluding that the Veteran in fact had any present elbow disabilities. Nor did Dr. J.M. examine the Veteran. And Dr. J.M relied on the Veteran's documented right elbow scar as evidence that in-service injuries occurred, without acknowledging that this elbow scar was noted on entrance into service and thus preexisted any in-service injury, event, or disease.

In contrast, December 2023 VA examinations found no diagnosable elbow disability and a scar on the right elbow but none on the left. The elbow examination also noted normal range of motion without any evidence of pain and found no functional impact. These examinations are consistent with the Veteran's treatment history (or lack thereof) and thus warrant greater probative weight.

The Board acknowledges the Veteran's reports of bilateral elbow pain and a left elbow scar, specifically his reports that he experienced pain when sleeping on his side or when lifting anything over five pounds. The Veteran is competent to report lay-observable symptoms. Layno, 6 Vet. App. at 470. However, the Veteran has not sought treatment for any disability of the elbows and did not exhibit pain or a left elbow scar when examined. The Board gives more probative weight to the medical evidence of record and finds that the evidence is persuasively against any functional impairment of earning capacity due to right elbow pain, left elbow pain, or left elbow scar.

The Veteran has admittedly not received a VA opinion regarding the etiology of his claimed right elbow pain, left elbow pain, or left elbow scar. However, no examination was required under either McLendon v. Nicholson, 20 Vet. App. 79 (2006) or the PACT Act.

Under McLendon, 20 Vet. App. at 83, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim.

In this case, the first McLendon element is not met, as there is no competent evidence of a diagnosis or functional impairment of earning capacity due to persistent or recurrent symptoms of right elbow pain, left elbow pain, or left elbow scar during or approximate to the pendency of this appeal.

Nor was an examination required under the PACT Act. Admittedly, the Veteran has participation in a toxic exposure risk activity (TERA) due to asbestos exposure. See 38 U.S.C. § 1119. Although VA has an obligation to obtain medical opinions for any service connection claim which cannot be granted where there is evidence of a TERA and of a disability, VA has identified several exceptions to this general obligation where there is no indication of an association between the disability and the TERA. See 38 U.S.C. § 1168(b). Specifically, a TERA opinion is not required for disabilities resulting from physical trauma; mental disorders; disabilities that have not been shown to have any positive association with herbicide exposure; and disabilities that manifested during service or with a clear etiology that is not associated
Veteran has participation in a toxic exposure risk activity (TERA) due to asbestos exposure. See 38 U.S.C. § 1119. Although VA has an obligation to obtain medical opinions for any service connection claim which cannot be granted where there is evidence of a TERA and of a disability, VA has identified several exceptions to this general obligation where there is no indication of an association between the disability and the TERA. See 38 U.S.C. § 1168(b). Specifically, a TERA opinion is not required for disabilities resulting from physical trauma; mental disorders; disabilities that have not been shown to have any positive association with herbicide exposure; and disabilities that manifested during service or with a clear etiology that is not associated with toxic exposure. See VBA Letter 20-22-10 at 10-13, Processing Claims Involving the PACT Act, 87 Fed. Reg. 78,543 (Dec. 22, 2022). In this case, the Veteran's claimed right elbow pain, left elbow pain, and left elbow scar are either disabilities resulting from physical trauma or disabilities with a clear etiology not associated with toxic exposure (specifically, being caused by his cervical spine/neck condition). Thus, an exception to the TERA opinion requirements applies, and remand for an examination is not warranted on this basis.

The Veteran has also not received a VA medical opinion regarding whether his right elbow pain, left elbow pain, or left elbow scar were caused or aggravated by his cervical spine/neck condition. However, the Veteran was not service connected for a cervical spine/neck condition at the time of the AOJ decision on appeal. Thus, there was no pre-decisional error in the duty to assist in not obtaining such an opinion, and remand to obtain such an opinion is not warranted. 38 C.F.R. § 20.802

(a).

As the evidence is persuasively against the claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F.4th at 777-79. Service connection is denied.

8. Service connection for right elbow scar

The Veteran asserts entitlement to service connection for a right elbow scar. Although this scar preexisted service, the Veteran asserts that his service aggravated this disability. For the following reasons, service connection for such aggravation is granted.

In Wagner v. Principi, 370 F.3d 1089, 1096 (2004), the United States Court of Appeals for the Federal Circuit held if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case, 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish an increase in disability during service. If the presumption of aggravation attaches, the burden shifts to the government to show by clear and unmistakable evidence that there has been no increase in the severity of the preexisting condition or that any increase was the result of natural progression. Id; see also 38 C.F.R. § 3.306(b).

In this case, the Veteran's July 1983 and July 1984 entrance examinations both document a right elbow scar. A December 2023 VA examination confirmed that this scar was still present.

At the examination, the Veteran reported that his right elbow scar became more pronounced and grew in size during his active service. The evidence of record thus shows that there was an increase in the severity of the Veteran's right elbow scar during service, and the presumption of aggravation attaches.

In order to rebut the presumption of aggravation, there must be clear and unmistakable evidence that there has been no increase in the severity of the preexisting condition or that any increase was the result of natural progression. 38 C.F.R. § 3.306. Clear and unmistakable evidence is defined as obvious or manifest. 38 C.F.R. § 3.306(b). Clear and unmistakable evidence means that the evidence "'cannot be misinterpreted and misunderstood, i.e., it is undebatable.'" Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009).

In this case, there is not clear and unmistakable evidence that there was no increase in severity or that the increase in severity was due to the natural progression of the disease. No competent medical source has offered any opinion as to whether the Veteran's right elbow scar clearly and unmistakably did not increase in severity during service or whether such increase was clearly and unmistakably the result of natural progression. And making such a determination requires medical expertise that the Board may
. § 3.306(b). Clear and unmistakable evidence means that the evidence "'cannot be misinterpreted and misunderstood, i.e., it is undebatable.'" Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009).

In this case, there is not clear and unmistakable evidence that there was no increase in severity or that the increase in severity was due to the natural progression of the disease. No competent medical source has offered any opinion as to whether the Veteran's right elbow scar clearly and unmistakably did not increase in severity during service or whether such increase was clearly and unmistakably the result of natural progression. And making such a determination requires medical expertise that the Board may not exercise in the first instance. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991).

Therefore, the presumption of aggravation has not been rebutted, and service connection based upon aggravation of a pre-existing disability is granted. 38 U.S.C. § 1153; 38 C.F.R. § 3.306.

REASONS FOR REMAND

1. Service connection for cervical spine/neck condition is remanded.

The Veteran asserts entitlement to service connection for a cervical spine/neck condition, asserting that this disability began in service or is related to service.

Unfortunately, the Board is unable to grant service connection at this time. No competent medical source has provided a persuasive medical opinion that the Veteran's cervical spine/neck condition is related to service. And the determination of whether a nexus exists requires medical expertise that the Board may not exercise in the first instance. See Colvin, 1 Vet. App. at 175. And although degenerative disc disease, as arthritis, is a chronic disease listed in 38 C.F.R. § 3.309(a), the present record does not support a finding that the Veteran's cervical spine/neck condition was noted as chronic in service or has had continuity of symptomatology since service.

Admittedly, Dr. J.M. opined that the Veteran's neck pain was related to service. Unfortunately, the Board is unable to grant this opinion persuasive weight at this time. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez, 22 Vet. App. at 302-04. Here, Dr. J.M. explained only that repetitive injuries "can" cause cervicalgia. However, Dr. J.M. did not provide any reasoning grounded in the facts of this case for concluding that the Veteran's cervical spine/neck condition was related to service.

That said, remand is necessary to correct a pre-decisional error in the duty to assist. 38 C.F.R. § 20.802(a). Specifically, although the Veteran received a VA medical examination, the Veteran has not received a VA medical opinion regarding the etiology of his cervical spine/neck condition. When VA undertakes to obtain an examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).

Remand is necessary to obtain an addendum opinion.

2. Entitlement to an initial evaluation in excess of 50 percent for PTSD prior to November 21, 2022, is remanded.

The Veteran is presently in receipt of a 50 percent initial evaluation for PTSD prior to November 21, 2022, and a 70 percent evaluation from November 21, 2022. On appeal, the Veteran asserts entitlement to a 70 percent evaluation prior to November 21, 2022.

Unfortunately, remand of this issue is required, as the appropriate evaluation for the Veteran's PTSD is inextricably intertwined with evaluation of his TBI.

Evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where symptoms of a TBI and a comorbid mental disorder overlap, a single evaluation is to be assigned under either the rating criteria for a TBI or for the mental disorder, whichever results in the better assessment of overall impairment. 38 C.F.R. § 4.124a, Diagnostic Code 8045, n.1.

In this case, symptoms of the Veteran's PTSD overlap at least partially with symptoms of his TBI, including memory loss, irritability, and aggression. Moreover, the August 2023 VA examiner opined that it was not possible to differentiate the symptoms of these disabilities.

In light of the above grant of service connection for TBI, the AOJ will assign an evaluation for the Veteran's TBI in the first instance. As explained above, that evaluation could significantly affect evaluation of the Veteran's PTSD. The issues are thus inextricably intertwined, and
disorder, whichever results in the better assessment of overall impairment. 38 C.F.R. § 4.124a, Diagnostic Code 8045, n.1.

In light of the above grant of service connection for TBI, the AOJ will assign an evaluation for the Veteran's TBI in the first instance. As explained above, that evaluation could significantly affect evaluation of the Veteran's PTSD. The issues are thus inextricably intertwined, and remand of the issue of entitlement to an initial evaluation in excess of 50 percent for PTSD is required.

The matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician to determine the nature, severity, and etiology of the Veteran's cervical spine/neck condition. An examination should only be scheduled if the clinician deems one is necessary to provide the requested opinions.

The examiner should opine as to whether the cervical spine/neck condition is related to an in-service event, injury, or disease.

A rationale for all opinions must be provided. If the examiner cannot provide an opinion without resort to speculation, he or she must explain why an opinion cannot be provided (e.g., lack of sufficient information or evidence, the limits of medical knowledge, etc.).

2. Re-adjudicate the claims.

D. SMART

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board D. Mansfield, 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.

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