Citation Nr: 1637121 Decision Date: 09/22/16 Archive Date: 09/30/16 DOCKET NO. 12-30 431 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or diabetic neuropathy. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to hypertension or service-connected diabetes mellitus and/or diabetic neuropathy. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD D. Casula, Counsel INTRODUCTION The Veteran served on active duty from May 1966 to June 1969. This case is before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified before the undersigned Veterans Law Judge at a travel Board hearing from the RO in June 2016. A transcript of the hearing has been associated with the claims file. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Virtual VA electronic claims file. Virtual VA contains documents that are either duplicative of the evidence in VBMS or not relevant to the issue on appeal. The issue of entitlement to service connection for hypertension addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The most probative evidence of record indicates that erectile dysfunction is caused by the Veteran's service-connected diabetes mellitus and the medications taken for his service-connected diabetic neuropathy. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction have been met. 38 U.S.C.A. § 1110, 5107 (West 2014); 38 C.F.R. § 3.310 (2015) REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that his erectile dysfunction is either caused or aggravated by his service-connected diabetes mellitus or diabetic neuropathy, or his hypertension or medications taken for hypertension. See June 2016 Board hearing transcript. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2015). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2015). In addition, service connection for certain chronic diseases, including sensorineural hearing loss and tinnitus (organic diseases of the nervous system), may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a) (2015); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2015); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A disability can also be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Moreover, secondary service connection may be established, as well, by any increase in severity or aggravation of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Here, the first element of service connection is met as there are diagnoses of erectile dysfunction. See e.g., October 2009 VA examination; November 2008 private medical opinion. The second element of secondary service connection is met as diabetes mellitus and diabetic neuropathy of the bilateral upper and bilateral lower extremities are service-connected. See November 2009 Rating Decision; August 2012 Decision Review Officer Decision. The issue, then, is whether the ED is caused or aggravated by either of those two service-connected disabilities. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448. There are multiple medical opinions of record. Initially, an October 2009 VA examination report contained a negative nexus opinion. The examiner opined that the ED began prior to the diagnosis of diabetes and was not caused by hypertension or his hypertension medication. A later VA examination noted that diabetes was diagnosed in 2005. A November 2008 private medical opinion from a private treating physician noted a diagnosis of organic impotence due to diabetes and hypertension. In a January 2009 letter, the Veteran's treating physician noted that the erectile dysfunction was secondary to both diabetes, hypertension, and depression medications. In a September 2012 opinion, a private provider opined that erectile dysfunction was secondary to diabetes and hypertension and the medications taken for these conditions. In an October 2012 submission, a private provider opined that the Veteran's ED was caused by diabetes mellitus and the medications taken for his diabetic neuropathy, which also have urogenital side effects. The Board does not find the VA examination significantly probative as it does not address the medications taken for his diabetes and diabetic neuropathy. The Board also does not find the 2008, 2009, and September 2012 private opinions probative as they provide opinions based in part on a condition that is not yet service-connected. The October 2012 private opinion, however, links the Veteran's ED to service-connected disorders and the medications taken therefor. The Board accords this opinion significant probative value. Accordingly, and resolving all reasonable doubt in the favor of the Veteran, the Board concludes that service connection for ED is warranted. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303 (2015). ORDER Service connection for ED is granted. REMAND The appellant contends that his hypertension is related to his service-connected diabetes mellitus and/or his service-connected peripheral neuropathy. He has also contended that his hypertension was caused by medication (Cymbalta) that he was prescribed for peripheral neuropathy. He testified that he was prescribed Cymbalta in February 2005; the dosage of Cymbalta was increased in March 2005; in April 2005, his blood pressure increased and he was started on medication for hypertension; and in July 2005 he started treatment for diabetes mellitus. On a VA examination in October 2009, it was noted that hypertension was diagnosed in 2005. The examiner opined that hypertension was not a complication of diabetes, noting that it began at the same time as the diabetes mellitus and that there was no albuminuria. The examiner also opined that the appellant's hypertension was not worsened or increased by his diabetes. In a letter dated in October 2012, a private cardiologist reported that the Veteran had been under his care for many years, and advised that after reviewing the medical history, he found that hypertension was diagnosed after being treated with Cymbalta. In a letter dated in August 2014, a private physician noted treating the Veteran since 2012. The physician noted that the Veteran had chronic renal disease, stage III, secondary to diabetes mellitus, type 2, and diabetic neuropathy with constant albuminuria, intermittent edema, and an approximate 50 percent decrease in kidney function. In view of the conflicting opinions as to a causal relationship, an addendum opinion must be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran's hypertension from a VA examiner. The entire claims file should be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide the following opinions; (a) is it at least as likely as not that that hypertension is caused by the Veteran's diabetes mellitus? (b) is it at least as likely as not that that hypertension is caused by the Veteran's diabetic neuropathy? (c) is it at least as likely as not that that hypertension is caused by the medications taken for the Veteran's diabetes mellitus and/or diabetic neuropathy? (d) is it at least as likely as not that that hypertension is aggravated by the Veteran's diabetes mellitus? (e) is it at least as likely as not that that hypertension is aggravated by the Veteran's diabetic neuropathy? (f) is it at least as likely as not that that hypertension is aggravated by the medications taken for the Veteran's diabetes mellitus and/or diabetic neuropathy? The examiner must address the prior opinions of record and the timeline of the prescriptions of Cymbalta and the hypertension medications. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs