Citation Nr: 1553602 Decision Date: 12/23/15 Archive Date: 12/30/15 DOCKET NO. 09-24 409 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for erectile dysfunction. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. Fraser, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1987 to November 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a February 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The RO in San Diego, California currently has jurisdiction over the Veteran's claim. REMAND Additional development is required before the Veteran's claim for service connection for erectile dysfunction is decided. At the outset, VA's duty to assist includes the conduct of a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69, 76 (1995). A VA examination is necessary prior to final adjudication of a claim 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 Veteran qualifies, and (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) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2) (West 2014); 38 C.F.R. § 3.159(c)(4)(i) (2015); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Service connection is in effect for residuals of a traumatic brain injury (TBI), as well as migraine headaches. In April 2009, the Veteran filed a claim to reopen the previously denied claim for service connection for erectile dysfunction. The Veteran subsequently averred that his service-connected TBI caused his erectile dysfunction. A July 2013 Board decision found new and material evidence had been submitted to reopen the Veteran's claim; however the Board found additional development was necessary before the claim was decided. In September 2013, the Veteran underwent a VA examination. The examiner diagnosed erectile dysfunction. In the course of the examination, the Veteran reported experiencing erectile dysfunction since he sustained his TBI in 1988. More specifically, the Veteran indicated that he started to have difficulty maintaining an erection within months of his head injury, and also experiences migraine headaches when he has erections, which interfered with his ability to obtain and maintain an erection. Following a review of the evidence of record and the examination of the Veteran, the examiner determined the Veteran's erectile dysfunction "is less likely than not (less than 50 percent probability) proximately due to or the result" of his service-connected TBI. In support of this opinion, the examiner stated the Veteran's outpatient treatment notes show sporadic treatment for erectile dysfunction for several years following his discharge from active duty, with evidence indicating "SOME erectile function nearly 20 years after his injury." The examiner also noted the Veteran's previous reports that his erectile dysfunction manifested after his in-service cystoscopy procedure that occurred several years after his head injury. In addition, the examiner stated the Veteran's "TBI is not severe" and could find nothing in the literature that she reviewed that linked erectile dysfunction to TBI. Based on these facts, the examiner concluded the Veteran's erectile dysfunction was "less likely than not" caused by his TBI. However, the examiner failed to explain why these facts led to her conclusion. Specifically, the examiner did not explain why she discounted the Veteran's reports of some degree of erectile problems following his in-service head injury, or why the severity of the Veteran's TBI was an important factor in determining whether this disability could have proximately caused or aggravated the Veteran's erectile dysfunction. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In addition, the examiner went on to note many entries in the Veteran's outpatient treatment notes showing treatment for migraines, and the Veteran indicated some correlation between his migraine headaches and his erectile dysfunction. The examiner then stated "this question may be worth pursuing." In this regard, the examiner indicated there may be a causative relationship between the Veteran's service-connected migraines and his erectile dysfunction. In sum, the September 2013 examiner failed to provide an adequate rationale to support her opinion relative to whether the Veteran's erectile dysfunction was proximately caused or aggravated by his service-connected TBI, and also raised a new potential theory of service connection as secondary to the Veteran's migraine headaches. As such, a remand is necessary in order to obtain an addendum medical opinion addressing these matters. Accordingly, the case is remanded for the following action: 1. Contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Based on his response, attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of his response, obtain all outstanding VA records relevant to the claim being remanded. If, after making reasonable efforts the identified records are not obtained, notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. After completion of the above, an addendum medical opinion must be obtained from the September 2013 VA examiner. The evidence of record, in the form of electronic records, must be made available to the examiner, and the examiner must specify in the addendum medical opinion report that these records have been reviewed. Relative to the Veteran's claimed erectile dysfunction, the examiner must indicate the following: a) whether any degree of the Veteran's erectile dysfunction was proximately caused by his service-connected TBI; b) whether any degree of the Veteran's erectile dysfunction was aggravated by his service-connected TBI; c) whether any degree of the Veteran's erectile dysfunction was proximately caused by his service-connected migraine headaches; and d) whether any degree of the Veteran's erectile dysfunction was aggravated by his service-connected migraine headaches. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. The RO must review the addendum medical opinion to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures at once. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claim on appeal must be readjudicated. If the benefit on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence and argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).