Citation Nr: 1341659 Decision Date: 12/17/13 Archive Date: 12/31/13 DOCKET NO. 06-38 953 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for a bladder disorder, claimed as a neurogenic bladder. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Veteran served on active duty from November 1988 to November 1992. This matter comes to the Board of Veterans' Appeals (Board) from a May 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In April 2013, this matter was last before the Board, at which time it was remanded for further development. This appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required. REMAND In October 2012, VA obtained a medical opinion on the Veteran's urinary urgency. The reviewing examiner relied on an April 2012 clinical record as the sole source of information regarding the Veteran's claimed condition, and noted that the Veteran had been assessed as having benign prostate hypertrophy (BPH) with urinary urgency. The examiner concluded that it was less likely than not that the condition was related to the Veteran's service-connected peripheral neuropathy of the lower extremities. He also concluded that BPH with urinary urgency was less likely than not aggravated by his service-connected peripheral neuropathy or low back disability, or that the condition underwent an increase in severity due to these service-connected conditions. In this regard, the examiner explained that "standard medical textbooks do not identify a connection between [BPH] and either peripheral neuropathy or low back disability including degenerative disk disease." The Veteran's representative has taken issue with the October 2012 opinion, arguing that the opinion contains insufficient rationale. The Board agrees. First, the evidence of record shows documented assessments of BPH, diabetes mellitus and chronic kidney disease (CKD), each with urinary symptoms. The October 2012 VA opinion is inadequate as it does not address these diagnoses. Additionally, the examiner's rationale that merely cites a "standard medical textbooks" is insufficient. To be adequate, a medical opinion must do more than state a conclusion; rather, the medical examiner must support his or her conclusion with sufficient rationale and explanation. Stefl v. Nicholson, 21 Vet. App. at 123 (citing Tucker v. West, 11 Vet. App. 369, 374 (1998)). Accordingly, the Board finds that the medical opinion should be returned. 38 C.F.R. § 4.2. Accordingly, the case is REMANDED for the following action: 1. Return the case to the same VA physician who authored the October 2012 opinion, if possible, to review the claims folder and determine whether any bladder disorder(s) has/have undergone any permanent increase in severity due to his service-connected low back disability and associated peripheral neuropathy of the lower extremities. If the October 2012 VA physician is unavailable, the claims folders should be referred to another appropriate examiner in order to render the requested medical opinion. The claims folder and a copy of this remand must be made available to the examiner for review, and the examiner must specifically note that such review was accomplished. In regard to assessed bladder/urinary conditions, the examiner's attention is directed to the documented assessments of BPH, diabetes mellitus and chronic kidney disease (CKD). a. For any and all bladder disorder(s) diagnosed, the examiner must state whether it is at least as likely as not (a 50 percent or greater probability) that any such bladder disorder(s) has/have been caused by the service-connected low back disability and/or associated peripheral neuropathy of the lower extremities. b. In addition, for any and all bladder disorder(s) diagnosed, the examiner must state whether it is at least as likely as not (a 50 percent or greater probability) that any such bladder disorder(s) was/were aggravated/underwent a permanent increase in severity due to the Veteran's service-connected low back disability and/or his service-connected peripheral neuropathy of the lower extremities. If so, the examiner must specify the degree of increase in severity over and above the preexisting base line of disability. If the examiner finds that an interview with the Veteran and/or diagnostic testing is necessary, such should be accomplished. A complete rationale for any opinion offered must be provided. If the examiner cannot answer any question without resorting to mere speculation, the examiner should state why this is so. Aggravation is defined for legal purposes as a permanent worsening of the underlying condition versus a temporary flare-up of symptoms. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 2. After the development requested above has been completed to the extent possible, and after conducting any additional indicated development, to include obtaining any VA examinations, the AMC/RO should again review the record and adjudicate the claims on appeal. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto before this case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter 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 Supp. 2013). _________________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).