Citation Nr: 1325936 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 11-26 910 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected coronary artery disease. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected coronary artery disease and/or diabetes mellitus, type II. REPRESENTATION Veteran represented by: Connecticut Department of Veterans Affairs ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1966 to November 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, that, in pertinent part, denied service connection for hypertension and erectile dysfunction (ED). The Veteran requested a Travel Board hearing on his October 2011 VA Form 9. However, in a subsequent communication received in December 2011, he withdrew his request for a Board hearing. Accordingly, the Veteran's hearing request is considered withdrawn. 38 C.F.R. § 20.704(e) (2012). The issue of entitlement to service connection for hypertension, to include as secondary to service-connected CAD or diabetes mellitus, type II (DM), is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDING OF FACT The Veteran's currently diagnosed erectile dysfunction is the result of his service-connected coronary artery disease. CONCLUSION OF LAW Erectile dysfunction was incurred in or aggravated by a service-connected disability. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) The claim for service connection for erectile dysfunction has been granted, as discussed below. Any error related to the VCAA is moot. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claim The Veteran alleges that he currently suffers from ED as a result of his service-connected CAD or the medications he takes for it. Therefore, he believes that service connection is warranted on a secondary basis. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 39 C.F.R. § 3.310(b) (2012); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The medical evidence reveals that the Veteran has been diagnosed with ED. Specifically, a November 2010 letter from the Veteran's primary care physician, Dr. C. J. S., indicates that he has diagnosed the Veteran with ED. As such, the first element of Wallin is met. The Veteran is service connected for CAD, status post stent and coronary artery bypass graft with congestive heart failure and atrial fibrillation, and DM. The second element of Wallin is also met. With respect to the remaining nexus evidence, the Veteran submitted a letter from his private primary care physician in March 2010. Dr. C. J. S. stated that there is a clearly established association in medical literature linked CAD and ED. He opined that the Veteran's ED developed progressively, which is the nature of ED associated with CAD. He further opined that the Veteran's cardiac medications may contribute to his ED as well. In light of the March 2010 positive private opinion linking the Veteran's service-connected CAD with his ED and the lack of sufficiently probative medical evidence to contradict this, the Board finds that the medical evidence in this case is, at minimum, in equipoise regarding the question of whether the Veteran's current ED is related to his service-connected CAD. As such, the benefit-of-the-doubt will be conferred in the Veteran's favor and his claim for service connection for ED is granted on a secondary basis. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for erectile dysfunction is granted on a secondary basis. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the Board's adjudication of the Veteran's claim of entitlement to service connection for hypertension, to include as secondary to service-connected CAD and/or DM. The Veteran was afforded a VA hypertension examination in August 2010. At that time, the examiner diagnosed him with hypertension and suggested that his hypertension began in service. However, the "positive" opinion was based solely on a history reported to the examiner by the Veteran and without review of the claims file. There are no service treatment records indicating that the Veteran was treated in service for hypertension. Further, the examiner failed to provide an opinion on whether the Veteran's hypertension was secondary to his now service-connected CAD or ED. In light of these deficiencies, the August 2010 VA examiner's opinion is not sufficient to render a decision on the issue of service connection for hypertension, to include as secondary to a service-connected disability. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As the United States Court of Appeals for Veterans Claims (Court) explained in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), the Board may consider only independent medical evidence to support its medical findings. The Court went on to say that, if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. See Colvin at 175. For the reasons described above, the Veteran's claim of entitlement to service connection for hypertension, to include as secondary to service-connected CAD or DM, must be remanded for an addendum opinion. As the case is being remanded, the Board will take the opportunity to obtain any VA treatment records not yet associated with the claims file. Accordingly, the case is REMANDED for the following actions: 1. Copies of all outstanding VA treatment records from the West Haven VA Medical Center, and any other VA facility identified by the Veteran, should be obtained and added to the claims folder. 2. Following completion of the above, the Veteran's claims file should be returned to the original August 2010 VA examiner, if possible, for an addendum opinion. The claims folder should be provided to the examiner for review of pertinent documents therein in connection with the examination, and the examination report should reflect that such a review was conducted. Specifically, the examiner should provide an opinion on the following: a. Whether it is at least likely as not (a 50 percent probability or greater) that the Veteran's current hypertension had its onset in service or within one year of service discharge or is otherwise shown to be etiologically related to his active service. b. Whether it is at least likely as not (a 50 percent probability or greater) that the Veteran's current hypertension was caused or aggravated (permanently increased in severity beyond the natural progression of the disorder) by his service-connected coronary artery disease and/or diabetes mellitus. If the August 2010 VA examiner is unavailable, the Veteran should be afforded an examination with an appropriate examiner in order to address the above questions. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After completing the above actions and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim of entitlement to service connection for hypertension, to include as secondary to service-connected coronary artery disease and/or diabetes mellitus, should be readjudicated. If the claim remains denied, a supplemental statement of the case should be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, the case should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board advises him that the conduct of the efforts as directed in this remand, and any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is critical and appreciated. He is also advised that failure to report for any scheduled examination may result in the rating of the claim on the evidence of record if it is an original claim or denial if it is a claim to reopen or for increase. See 38 C.F.R. § 3.655(b) (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs