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Updated Jan 10, 2024

In This Section
 This section contains the following topics:
Topic
Topic Name
1
2

1.   TBI

Introduction
This topic contains information about TBI, including
Change Date
January 10, 2024

V.iii.12.B.1.a.  Definition: TBI
The term traumatic brain injury (TBI) means the physical, cognitive, and/or behavioral/emotional residual disability resulting from an event of external force causing an injury to the brain.

V.iii.12.B.1.b.    TBI Events
The TBI event is a traumatically induced structural injury and/or physiological disruption of brain function resulting from an external force indicated by at least one of the following clinical signs immediately following the event:
  • any period of loss of consciousness or decreased consciousness
  • any loss of memory for events immediately before or after the injury
  • any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.)
  • neurological deficits, whether or not transient, or
  • intracranial lesion.
Notes:
  • The TBI event has two necessary components: the external force and the identifiable acute manifestations of brain injury immediately following the external force.  Not all individuals exposed to an external force will have brain injury, and therefore, they will not meet the criteria for having a TBI event.
  • The acute manifestations may resolve without chronic disability, or a chronic disability may result.
  • Although unconsciousness or reduced consciousness is common in TBI events, these are not required.  Any one of the five signs will be sufficient.

V.iii.12.B.1.c.  External Force for the Purpose of TBI Events
External force means any of the following events:
  • a foreign body (such as a bullet or shell fragment) penetrating the brain
  • the head being struck by an object (such as a fist, a hatch, or flying debris)
  • the head striking an object (such as the ground or a windshield)
  • the brain undergoing an acceleration/deceleration movement without direct external trauma to the head
  • force generated from events such as a blast or explosion, to include low-level blasts or explosions from firing heavy weapons systems or explosives, such as
    • artillery weapons, or
    • shoulder-launched missiles, or
  • other force yet to be defined.
Note:  TBI events may occur during combat or non-combat situations (such as a motor vehicle accident, fall, or personal assault).

V.iii.12.B.1.d.    TBI Residuals
The resultant disabling effects of a TBI event beyond those that follow immediately from the acute injury to the brain are known as TBI residuals or TBI sequelae.
The signs and symptoms of TBI residuals can be organized into the three main categories of physical, cognitive, and behavioral/emotional residuals for evaluation purposes.  Examples of TBI residuals in each of the three categories may include, but are not limited to, those listed below.
Physical
Cognitive
Behavioral/Emotional
Apraxia (inability to execute purposeful, previously learned motor tasks, despite physical ability and willingness)
Dementias (pre-senile Alzheimer’s type, dementia pugilistica, post traumatic dementia)
Depression
Aphasia (difficulty communicating orally and/or in writing)
Attention and concentration deficits
Agitation and irritability
Paresis (muscle weakness or incomplete paralysis)
Memory, processing, and learning impairment
Impulsivity
Plegia (paralysis or stroke)
Language deficiencies
Aggression
Dysphagia (difficulty swallowing)
Planning difficulties
Anxiety
Disorders of balance and coordination
Judgment and control difficulties
Posttraumatic stress disorder (PTSD)
Diseases of hormone deficiency
Reasoning and abstract thinking limitations
Parkinsonism
Self-awareness limitations
Nausea/vomiting
Headaches
Dizziness
Blurred vision
Seizure disorder
Sensory loss
Weakness
Sleep disturbance
 
Note:  TBI residuals can resolve in a short period of time or can persist chronically or even permanently. Chronic TBI residuals may include some or all of the clinical signs that developed immediately during the TBI event. Others (such as seizures or spasticity) may have a delayed onset.

V.iii.12.B.1.e.  Determining the Issues in TBI Cases
A claim for service connection (SC) for TBI may also be worded as a claim for “head injury” or “concussion.”  A claim document mentioning any of the above must be sympathetically read and understood as a claim for all identifiable TBI residuals that can be attributed to one or more TBI events.
A claim for “combat injuries,” assault, automobile accident, fall, or other injurious events may also raise the issue of a TBI if there was an injury to the head.
As recognized by 38 CFR 4.124a, diagnostic code (DC) 8045, the external force of a claimed TBI event may result not only in brain injury but also in physical or psychological disorders distinct from brain injury residuals.  An explosion, for example, may cause burns, muscle injuries, orthopedic injuries including amputations, and PTSD in addition to a brain injury.  A TBI claim mentioning a specific traumatic event must be sympathetically read as a claim for SC for all disabling chronic residuals of the event.
 
Reference:  For more information on determining the issues, see M21-1, Part V, Subpart ii, 3.A.

V.iii.12.B.1.f.     SC of TBI Residuals
Brain injuries, even if mild, cause permanent changes within the brain.  Even if residual impairment is not detected upon examination, the brain has been damaged in some way that is permanent in nature.  When there is a current formal diagnosis of TBI and a positive nexus linking the diagnosis to the in-service injury, 38 CFR 3.303 allows for SC on a direct basis, even when the current examination indicates the TBI is not manifesting any current signs or symptoms or that it is resolved.
Notes:
  • TBI residuals can manifest years after the initial injury.
  • A medical opinion is necessary when the medical evidence of record does not show a clear-cut etiology for a sign or symptom claimed as a delayed effect.
Example:  A Veteran files a new claim for SC of TBI in December 2019.  The Veteran’s service records show a mild head injury in 2010.  On the Initial Evaluation of Residuals of Traumatic Brain Injury Disability Benefits Questionnaire, the examiner selects the TBI diagnosis and marks all facets as normal.  Post-service medical records do not show any complaints of disabling signs or symptoms.
Result:  Grant SC for TBI under 38 CFR 4.124a, DC 8045, 0 percent.

V.iii.12.B.1.g.   Evaluation of TBI Residuals
Evaluate service-connected (SC) TBI residuals under 38 CFR 4.124a, DC 8045.
In every case, one evaluation should be assigned using the highest level of impairment assigned to any facet contained in the table “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified,” which has been incorporated into the Veterans Benefits Management System – Rating (VBMS-R).
Additional evaluations may be appropriate to assign as provided in M21-1, Part V, Subpart iii, 12.B.1.h and i.
 
Note:  A medical classification of severity of the TBI at the time of the acute trauma from the TBI event has no bearing on evaluation for Department of Veterans Affairs (VA) compensation purposes.  It is not an evaluation factor and is not relevant to the application of the benefit of the doubt rule.  Do not imply or state that initial severity classification was given weight in assigning a disability evaluation.
 
References:  For more information on

V.iii.12.B.1.h. Multiple Evaluations and Pyramiding in TBI Cases
In addition to the evaluation for TBI manifestations under the table “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” in 38 CFR 4.124a, DC 8045 (and also incorporated into VBMS-R), manifestations of a comorbid mental, neurologic, or other physical disorder can be separately evaluated under another DC if there is a distinct diagnosis – even if based on subjective symptoms – and no more than one evaluation is based on the same manifestation(s).
Follow the policy in the table below.
If manifestations …
Then …
are clearly separable
assign a separate evaluation using each applicable DC.
of two or more conditions cannot be clearly separated
assign a single evaluation under whichever set of criteria allows the better assessment of the overall impaired functioning due to both conditions.
 
References:  For more information on

V.iii.12.B.1.i.  Evaluating TBI and Comorbid Symptoms/ Conditions
Use the table below when evaluating TBI and comorbid symptoms and/or conditions.
If the Veteran has …
Then evaluate …
headaches
headaches according to the table below.
If the Veteran has …
Then …
subjective complaints of headaches
evaluate the subjective complaints as part of the TBI evaluation under 38 CFR 4.124a, DC 8045 rather than under a separate DC.
Note:  Occasional subjective headaches are not a distinct comorbid diagnosis.
a distinct comorbid diagnosis of a headache disorder
Examples:  Migraine headaches, post-concussive headaches, tension headaches
assign a separate evaluation under 38 CFR 4.124a, DC 8100 as long as the manifestations do not overlap with those used to assign the evaluation of TBI under 38 CFR 4.124a, DC 8045.
tinnitus
tinnitus based on one of the following methods, depending on which method results in a higher evaluation:
vertigo (whether referred to as “vertigo,” “constant vertigo,” “peripheral vestibular disorder,” “benign paroxysmal positional vertigo,” or any other similar wording)
vertigo in the subjective symptoms facet under 38 CFR 4.124a, DC 8045.
Note:  If vertigo was awarded a separate compensable evaluation prior to March 15, 2012, do not change or correct the evaluation.
Reference:  For more information on SC for vertigo, see M21-1, Part V, Subpart iii, 12.A.1.e.
cognitive and/or behavioral/emotional residuals
the symptoms according to the table below.
If …
Then …
the Veteran has subjective feelings of anxiety, depression, or other mental complaints
evaluate in the subjective symptoms facet under 38 CFR 4.124a, DC 8045.
Note:  Subjective mental complaints are not a distinct comorbid diagnosis.
  • the Veteran has a comorbid mental disorder and/or neurocognitive disorder, and
  • the examiner is able to delineate both
    • symptoms, and
    • occupational and social impairment
assign separate evaluations for
  • the Veteran has a comorbid mental disorder or neurocognitive disorder, and
  • the examiner is unable to delineate both
    • symptoms, and
    • occupational and social impairment
assign a single evaluation under the DC (either under 38 CFR 4.124a, DC 8045 or the appropriate 38 CFR 4.130 DC) that provides the higher evaluation based on overall impaired functioning due to both conditions.
Note:  This guidance applies to all cognitive and behavioral/emotional TBI residuals as defined in M21-1, V, Subpart iii, 12.B.1.d.  If separate and distinct physical symptoms due to TBI are present, evaluate them in the subjective or other applicable facet under 38 CFR 4.124a, DC 8045, as long as the physical symptoms are not the basis of an evaluation for another condition.

V.iii.12.B.1.j.  Example of Evaluating TBI With Comorbid Conditions
Situation:  VA examination shows the Veteran has numerous behavioral/emotional symptoms (depression that severely affects the Veteran’s work and family relationships, frequent suicidal thoughts, confusion, apathy, and unpredictability) and meets the diagnostic criteria for both TBI and major depression.  The examiner was unable to delineate which symptoms are associated with TBI and which are associated with major depression.  In addition, the TBI examination found multiple physical complaints related to TBI, including vertigo, sensitivity to light, blurred vision, and subjective headaches.  Evaluation under 38 CFR 4.130 criteria would result in the higher evaluation for the behavioral/emotional symptoms due to TBI and major depression.
Result:  Assign an evaluation for the behavioral/emotional residuals under 38 CFR 4.130, DC 9434.  Assign a separate evaluation under 38 CFR 4.124a, DC 8045 for the remaining physical symptoms and combine the evaluations under 38 CFR 4.25.

V.iii.12.B.1.k.  Opinion Evidence and Separate Evaluations of TBI and a Mental Disorder
Ensure that sufficiently clear and unequivocal medical opinion evidence exists in the claims folder whenever there is a question of whether TBI and a mental disorder are distinct and can be separately evaluated.  Veterans Benefits Administration decision makers are not qualified to make such determinations.
The opinion may be provided by either an examiner assessing the TBI or an examiner assessing the mental disorder as long as the individual offering the opinion is properly qualified.
If a medical provider cannot make the required determination without resorting to mere speculation, then careful consideration must be given to whether that statement can be accepted under Jones v. Shinseki, 23 Vet.App. 382 (2010).

V.iii.12.B.1.l.  Additional TBI Signs or Symptoms Upon Reevaluation
When considering a claim for reevaluation of TBI, do not automatically concede that a new sign, symptom, or diagnosis is a residual of TBI simply because it is listed in M21-1, Part V, Subpart iii, 12.B.1.d or in the evaluation criteria.
If there is not competent evidence that the sign, symptom, or diagnosis is associated with the SC TBI, obtain medical clarification.

V.iii.12.B.1.m.   TBI and SMC
Brain injuries may be associated with loss of use of an extremity, sensory impairments, erectile dysfunction, need for regular aid and attendance (A&A) (including need for protection from hazards of the daily living environment due to cognitive impairment), and being factually housebound or statutorily housebound.
Carefully consider eligibility for special monthly compensation (SMC) when evaluating TBI residuals.
 
References:  For more information on

V.iii.12.B.1.n.  Temporary Total Evaluations and TBI
In cases of recently discharged Veterans, consider the applicability of a temporary 50-percent or 100-percent prestabilization evaluation under the provisions of 38 CFR 4.28.
Lengthy VA hospitalizations or surgeries with convalescence may also implicate consideration of eligibility for temporary total evaluation under 38 CFR 4.29 and 38 CFR 4.30.

V.iii.12.B.1.o.  Training and Signature Requirements for TBI Decisions
All decisions that address TBI as an issue, including rating decisions, Statements of the Case, and Supplemental Statements of the Case, must only be worked/reviewed by a Rating Veterans Service Representative or Decision Review Officer who has completed the required TBI training.
Decisions for TBI require two signatures until a decision maker has demonstrated an accuracy rate of 90 percent or greater based on a review of at least 10 TBI cases.
 
References:  For more information on

V.iii.12.B.1.p.  Applicability of 38 CFR 3.114(a) in TBI Cases
The rating criteria for evaluating TBI were changed effective October 23, 2008.
Under Note (5) of 38 CFR 4.124a, DC 8045, a Veteran whose residuals of TBI are rated under a version of the diagnostic criteria in effect before October 23, 2008, may request review under the current regulation irrespective of whether the disability has worsened since the last review.  A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review, applying 38 CFR 3.114(a) as applicable.  However, in no case will the award be effective before October 23, 2008.
 
Reference:  For more information on liberalizing changes of law and VA issues, see M21-1, Part V, Subpart ii, 4.A.6.

V.iii.12.B.1.q.   TBI Special Issue
Ensure that the Traumatic Brain Injury special issue indicator has been added in all cases involving claims for TBI by reviewing the VBMS profile screen.
 
Reference:  For more information on special issue indicators, see

V.iii.12.B.1.r.  Anoxic Brain Injury
Anoxic brain injury is a condition resulting from a severe decrease in the oxygen supply to the brain that may be due to any of a number of possible etiologies, including trauma, strangulation, carbon monoxide poisoning, stroke, and many others.
As anoxic brain injury does not have its own unique DC in the rating schedule, it can be rated analogously, depending on the specific medical findings in a particular case.
Use the table below to determine the possible analogous rating.
If the residuals are similar to …
Then evaluate the symptoms analogous to …
TBI
brain hemorrhage
psychiatric disability
nerve damage
one or more DCs for specific nerves that are affected.
 
Important:  Follow the guidance in M21-1, Part V, Subpart iii, 12.B.1.h and i when considering the assignment of multiple evaluations for residuals.

2.  Secondary Conditions Associated With TBI

Introduction
This topic contains information on secondary conditions associated with SC TBI, including

Change Date
April 16, 2020

V.iii.12.B.2.a.  Secondary SC Under 38 CFR 3.310
38 CFR 3.310(d) was amended on December 17, 2013, to establish an association between TBI and certain illnesses.
In absence of clear evidence to the contrary, the following five diagnosable illnesses are held to be a secondary result of TBI:
  • Parkinsonism, including Parkinson’s disease, following moderate or severe TBI
  • unprovoked seizures, following moderate or severe TBI
  • dementias (presenile dementia of the Alzheimer’s type, frontotemporal dementia, and dementia with Lewy bodies), if the condition manifests within 15 years following moderate or severe TBI
  • depression, if the condition manifests within three years of moderate or severe TBI or within 12 months of mild TBI, or
  • diseases of hormone deficiency that result from hypothalamo-pituitary changes, if the condition manifests within 12 months of moderate or severe TBI.
Entitlement to secondary SC for these TBI-related conditions in 38 CFR 3.310(d) depends upon the initial severity of the TBI and the period of time between the injury and onset of the secondary illness.
 
Important:  There is no need to obtain a medical opinion to determine whether the above conditions are associated with TBI when there is a TBI of a qualifying degree of severity.
Notes:
  • Determine the initial severity level of the TBI based on the TBI symptoms at the time of the original injury, or shortly thereafter, rather than the current level of functioning.
  • Regional offices (ROs) must continue to follow guidance in M21-1 Part V, Subpart iii, 12.B.1 when evaluating residuals of TBI.  However, ROs must follow guidance in this topic when establishing secondary SC for claimants who have experienced a TBI in service and later develop one of the five diagnosable conditions listed in 38 CFR 3.310(d).
  • The determination of initial severity is adjudicative – although based on medical evidence.  That means the rating activity must decide the facts, such as initial severity, that correspond with the legal standard set forth in the regulation.
References:  For more information on

V.iii.12.B.2.b.  Evaluating the Initial Severity of TBI
For purposes of determining the initial severity of the TBI, consider the factors from the table in 38 CFR 3.310(d).  Review medical records and lay statements for evidence of
  • structural imaging of the brain, such as magnetic resonance imaging (MRI) or positron emission tomography (PET) scans
  • loss of consciousness (LOC)
  • alteration of consciousness/mental state (AOC), including disorientation
  • post-traumatic amnesia (PTA), including any loss of memory, and
  • Glasgow Coma Scale (GCS), which provides a measurement of the degree of coma at or after 24 hours.
Reference:  For more information on verifying in-service blast injuries, see M21-1, Part V, Subpart iii, 12.B.2.e.

V.iii.12.B.2.c.  Using the TBI Initial Severity Table in 38 CFR 3.310
The TBI does not need to meet all the criteria listed under a certain initial severity level in order to classify the TBI under that severity level.
If the Veteran’s TBI meets the criteria in more than one severity level, classify the initial severity at the highest level in which a criterion is met.
Because “normal structural imaging,” “abnormal structural imaging,” and “AOC greater than 24 hours” may be found at more than one severity level, classify severity based on other criteria in the table.  If no other criteria are present, then determine the level of severity as follows:
  • If AOC is greater than 24 hours and no other criteria are present, determine the severity as moderate.
  • If structural imaging is noted as normal and no other criteria are present, determine the severity as mild.
  • If structural imaging is noted as abnormal and no other criteria are present, determine the severity as moderate.
If the level of severity cannot be determined based on the available evidence, then apply the provisions of 38 CFR 3.310 (a) and (b) and order a VA examination/medical opinion as necessary.

V.iii.12.B.2.d. Evidence That May Be Relevant to the Initial Severity Factors
Evidence that may be relevant in ascertaining the initial severity of TBI symptoms includes
  • lay statements provided by the Veteran
  • lay statements from witnesses to the injury
  • history provided by the Veteran in medical reports, to include VA exams, and
  • service treatment records (STRs) findings at any time after the TBI.
Note:  The evidence that establishes the initial severity of the TBI does not necessarily have to be contemporaneous to the injury as long as it relates to the condition of TBI at or shortly after the time of the injury.
 
Example:  A Korean War Veteran submits a claim for SC for Parkinsonism secondary to his SC TBI.  The Veteran’s discharge examination from 1954 mentions a history of TBI in service.  However, it does not contain information sufficient to determine the level of severity of the initial TBI injury.  The Veteran provides a statement that he experienced a loss of consciousness during the Battle of Chosin Reservoir.  A review of prior VA examination reports reveals a history provided by the Veteran that he was told by fellow soldiers that he fell unconscious for almost an hour after two grenades exploded near him.
 
Analysis:  Although service records do not reveal the specific level of TBI during service, the Veteran’s statement is credible, consistent with circumstances of his service, and therefore sufficient to determine that he experienced a moderate level of TBI during service.

V.iii.12.B.2.e.  Registry for Verifying Blast Injuries
The U.S. Army Medical Research and Materiel Command Joint Trauma Analysis and Prevention of Injury in Combat (JTAPIC) has developed a registry of service members who were within 50 feet of a blast since mid-2010.
When existing Department of Defense records, to include STRs, are not sufficient to verify exposure to a blast injury that occurred since mid-2010, Compensation Service will contact JTAPIC to determine if there is a record of exposure.
 
Important:  E-mail Compensation Service at VAVBAWAS/CO/214DADVISORYANDSRT if exposure to an in-service blast injury from mid-2010 to the present cannot be verified.  Include the following information in the e-mail:
  • full name of Veteran
  • claim number and Social Security number
  • branch of service
  • brief description of the blast injury
  • location
  • date of blast/injury, and
  • unit.

V.iii.12.B.2.f.  Determination of Diagnosable Conditions as Secondary to TBI
Use the table below to determine secondary SC for conditions listed in 38 CFR 3.310(d).
If there is a diagnosis of …
And the initial severity of the TBI was …
Then …
Parkinsonism, including Parkinson’s disease
moderate or severe
award SC.
unprovoked seizures
moderate or severe
award SC.
dementia of the following types
  • presenile dementia of the Alzheimer type
  • frontotemporal dementia, and
  • dementia with Lewy bodies
moderate or severe
award SC if dementia manifested within 15 years after the TBI.
depression
moderate or severe
award SC if depression manifested within three years after the TBI.
mild
award SC if depression manifested within one year after the TBI.
a disease of hormone deficiency that results from hypothalamo-pituitary changes (any condition in the endocrine system section of the rating schedule, 38 CFR 4.119, DCs 7900-7912, or any condition evaluated analogous to one of those conditions)
moderate or severe
award SC if the condition manifested within one year after the TBI.

V.iii.12.B.2.g.  Considerations When Establishing Secondary SC
When evaluating TBI-related secondary conditions, avoid pyramiding when considering the initial TBI evaluation and symptoms that are now associated with the five secondary conditions.  Also, consider Notes 1 and 2 under 38 CFR 4.124a, DC 8045, while ensuring that the claimant receives the highest overall evaluation under the provisions of 38 CFR 4.25 (Combined Ratings Table).
Depending on the most advantageous combined evaluation, it is permissible to reduce an existing TBI evaluation as long as the overall evaluation of both TBI and the separate secondary SC condition is not reduced.  Use the combinator tool in VBMS-R to determine the combined evaluation of TBI and the secondary SC condition.  Thoroughly explain the decision in the Narrative section of the rating decision.
Use the table below to consider symptoms which apply to both TBI and the secondary conditions listed in 38 CFR 3.310(d).
If …
Then …
the symptoms associated with one of the five conditions were also used to provide the highest level of evaluation for any facet under 38 CFR 4.124a, DC 8045
  • consider removing evaluation of the facet, and
  • use the next highest-evaluated facet as the evaluation for the TBI residuals, as long as the symptoms of that facet are not used to establish SC for one of the five diagnosable conditions.
the same symptoms apply to both disabilities
  • evaluate the evidence and determine whether the symptoms can be entirely associated with one disability versus the other disability, and
  • do not request an additional medical examination for this determination.  If it is unclear, assume that the manifestations are not separable.
the same symptoms apply to both disabilities, and the symptoms are clearly associated with one disability versus the other disability
select the most advantageous option from the following:
Option
Actions
1
  • Remove symptoms from the TBI facet
  • evaluate the TBI under the next highest-evaluated facet that does not contain those symptoms
  • award secondary SC for the diagnosable condition, and
  • evaluate the secondary condition using those symptoms.
2
  • Keep the symptoms under the TBI facet, and
  • do not award secondary SC for the diagnosable condition, but
  • ensure the diagnosable condition is included with the description of the SC TBI disability in the rating decision.
3
  • Keep the symptoms under the TBI facet
  • award secondary SC for the diagnosable condition, and
  • evaluate based on the distinct symptoms.
 
Reference:  For more information on evaluating TBI residuals, see M21-1, Part V, Subpart iii, 12.B.1.g.

V.iii.12.B.2.h. Action When Evidence Shows a 38 CFR 3.310(d) Condition
Use the table below to determine how to proceed when evidence shows one of the five diagnosable conditions in 38 CFR 3.310(d).
If …
Then …
one of the five diagnosable conditions in 38 CFR 3.310(d) is identified in the evidence of record while processing a claim unrelated to SC TBI
a claim for that secondary condition must be invited.
evidence shows one of the five diagnosable conditions while evaluating a claim related to SC TBI
develop under normal claim processing procedures and make a determination on the secondary condition under the provisions of 38 CFR 3.310(d).

V.iii.12.B.2.i.  Determining Effective Dates for Secondary Conditions
The rule authorizing VA to establish the five secondary TBI-related conditions in 38 CFR 3.310 is effective January 16, 2014.
This rule will be applied to all cases pending before VA on or after January 16, 2014, and does constitute a liberalizing VA regulation under 38 U.S.C. 5110(g) and 38 CFR 3.114.  Apply these principles when determining effective dates and retroactive benefits.
 
Reference:  For more information on 38 CFR 3.114(a), see M21-1, Part V, Subpart ii, 4.A.6.