Citation Nr: 1616405 Decision Date: 04/26/16 Archive Date: 05/04/16 DOCKET NO. 11-22 078 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for otitis media, to include as secondary to service-connected tympanic membrane perforation of the left ear. 3. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected tympanic membrane perforation of the left ear, and/or otitis media. 4. Entitlement to service connection for tinnitus, to include as secondary to service-connected tympanic membrane perforation of the left ear, and/or otitis media. 5. Entitlement to service connection for erectile dysfunction, to include as secondary to PTSD and medications taken for PTSD, and/or diabetes mellitus and medications taken for diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. L. Wolinsky Associate Counsel INTRODUCTION The Veteran had active military service from February 1971 to November 1973 and from January 1974 to October 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in September 2009, and April 2011 by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In September 2015, the Veteran testified at a videoconference Board hearing conducted before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the claims file. The Board has recharacterized the issue of entitlement to service connection for depression/anxiety to more broadly include entitlement to service connection for an acquired psychiatric disorder, to include as due to service-connected PTSD, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, they are seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). The issue of entitlement to a total disability rating based on individual unemployability (TDIU) has been raised by the record in a statement made by the Veteran at his videoconference hearing, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See Hearing Transcript at 7. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issues of service connection for: (1) service connection for otitis media, to include as secondary to service-connected tympanic membrane perforation of the left ear, (2) service connection for hearing loss, to include as secondary to service-connected tympanic membrane perforation of the left ear, and/or otitis media, (3) service connection for tinnitus, to include as secondary to service-connected tympanic membrane perforation of the left ear, and/or otitis media, and (4) service connection for erectile dysfunction, to include as secondary to PTSD and medications taken for PTSD, and/or diabetes mellitus and medications taken for diabetes mellitus are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. The Veteran has been diagnosed with adjustment disorder with mixed anxiety and depressed mood; this disability did not manifest during, or as a result of, active military service, nor is it caused by or aggravated by a service-connected disability such as PTSD. 2. The Veteran has depression and anxiety that is contemplated by his already service connected PTSD. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for an acquired psychiatric disability other than PTSD, to include as secondary to PTSD, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The Board must discuss whether VA has complied with its duties to notify and assist the Veteran in substantiating his claims. In this respect, the Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)(2015). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). The notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). A letter sent to the Veteran in January 2011, advised the Veteran with what information or evidence is necessary to substantiate his service connection claim as well as his and VA's respective responsibilities in obtaining such evidence and information, and how VA determines the disability rating, and effective date. The January 2011 VCAA letter was sent prior to the rating decision in April 2011. Therefore, VA fulfilled its duty to notify. VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records, as well as obtaining a medical examination or opinion of the Veteran's disability when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The RO associated the Veteran's service treatment records (STRs) and VA treatment records with the claims file. As discussed below, the Board is remanding to procure SSA records. The Board finds that there is sufficient evidence of record to decide the claim and does not find a credible basis for delaying disposition of the issue decided herein. In August 2011, February 2014, and June 2015, VA provided the Veteran with PTSD examinations and obtained medical diagnoses for the Veteran's acquired psychiatric conditions. The examiners discussed the severity of the Veteran's acquired psychiatric conditions, and the extent of the Veteran's PTSD symptomatology. The examinations sufficiently discussed the Veteran's specifically claimed symptoms of depression and anxiety, and provided reasoned analysis to support the medical findings. As the etiology of the Veteran's acquired psychiatric disorders were fully discussed, the examinations are adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 30 3, 311-12 (2007) (holding that VA must ensure that the examination provided is adequate); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands that would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided). Additionally, the Board finds no prejudice under Bryant v. Shinseki, 23 Vet. App. 488 (2010). As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that the Veteran will not be prejudiced as a result of the Board's adjudication of his claim. Service Connection Service connection may be granted for a disability resulting from an injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, 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. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Additionally, the conditions at issue are not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore the presumptive provisions of 38 C.F.R. §§ 3.303(b) and 3.309(a) do not apply to these non-chronic diseases. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C.A. § 1112 (West 2014); 38 C.F.R. § 3.384 (2015). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). "The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant." Id. at 367. The Veteran has contended that his current acquired psychiatric disorders, in addition to PTSD, are related to active service, or are secondary to his service-connected PTSD. The Veteran has specifically contended that his depression and anxiety should be additionally service-connected. VAMC records show that the Veteran was assessed with adjustment disorder with depressed mood. A VAMC psychiatry note from October 2010, indicates that after review of the Veteran, he was diagnosed with Axis I anxiety and depression NOS. A March 2011 VAMC mental health note shows that the Veteran had a continued assessment of anxiety and depression NOS, which was improving. At the Veteran's August 2011 initial PTSD Disability Benefits Questionnaire (DBQ) the Veteran was diagnosed with an Axis I diagnosis of PTSD, and no other psychiatric disorders. In review of the Veteran's relevant mental health history, the examiner noted that the Veteran was prescribed citalopram and hydroxyzine, and was previously prescribed trazadone. The examiner noted that the Veteran was diagnosed with anxiety disorder not otherwise specified, and depression not otherwise specified. In review of the Veteran's symptoms, the examiner noted that the Veteran suffered from depressed mood, and anxiety in relation to his PTSD. The Veteran underwent a PTSD DBQ in February 2014. The Veteran was diagnosed with chronic PTSD, and adjustment disorder with mixed anxiety and depressed mood. The examiner noted that it was possible to differentiate what symptoms are attributable to each diagnosis. The examiner stated that the Veteran's PTSD caused arousal, avoidance, reexperiencing symptoms in relation to trauma, and that the Veteran's adjustment disorder caused mixed anxiety/depressive symptoms in relation to psychosocial stressors. The examiner noted that some symptoms overlap, notably irritability. The examiner further found that it was not possible to differentiate which portion of the Veteran's occupational and social impairment was caused by which mental disorder, noting that some symptoms overlap. In review of the Veteran's symptoms the examiner noted that the Veteran experiences depressed mood, and anxiety. In concluding remarks, the examiner noted that the Veteran's military related information symptoms appear to be exacerbated at least in part by current psychosocial stressors. The examiner also stated that the Veteran meets the DSM-V criteria for adjustment disorder due to current psychosocial stressors. The Veteran underwent a PTSD DBQ in June 2015. The examiner diagnosed the Veteran with chronic PTSD, and concluded that the Veteran did not have more than one mental disorder diagnosed. In review of the Veteran's PTSD symptoms the examiner noted that the Veteran experiences depressed mood, anxiety, and disturbances of motivation and mood. The Veteran also endorsed having anxiety, and that he experienced anxiety attacks. At the examination, the Veteran reported that his mood had been on the borderline of depression. After a review of the evidence, the Board notes a diagnosis of adjustment disorder, mixed with anxiety/depressive symptoms during the course of this appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007). The preponderance of the evidence, however, demonstrates that the Veteran is not entitled to service connection for an acquired psychiatric disability other than PTSD. The Board notes that the Veteran was assessed in-service with nervous anxiety in July 1978, and anxiety secondary to family problems while in-service in August 1978 and that the Veteran's Report of Medical History on discharge noted that he suffered from "depression or excessive worry", and "nervous trouble of any sort". However, the physician noted in review that the Veteran's depression and nervousness was self-resolving. Furthermore, there is no medical evidence that links the Veteran's in-service symptoms, or his service more generally to his current diagnosis of adjustment disorder, mixed with anxiety/depressive symptoms. Likewise the Veteran has not contended that his symptoms have continued since service, nor do the continuity and chronicity provisions of 38 C.F.R. § 3.303(b) apply to the diagnosis of adjustment disorder, mixed with anxiety/depressive symptoms. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Thus, the Veteran is not entitled to service connection on a direct basis. The Board also finds that the Veteran is not entitled to service connection for his adjustment disorder, mixed with anxiety/depressive symptoms on a secondary basis. The August 2011 VA examiner concluded that the Veteran's depression, and anxiety were symptoms of his PTSD and not a separately diagnosable condition. The June 2015 PTSD DBQ similarly noted that the Veteran's depressed mood, anxiety, and disturbances of motivation and mood were related to his PTSD. Thus, the Veteran's symptoms of depression and anxiety are already contemplated by the Veteran's service-connected PTSD. The February 2014 diagnosis of adjustment disorder with mixed anxiety and depressed mood was found to be related to his current psychosocial stressors, and not his military service. Indeed, the February 2014 VA examiner essentially found "reverse aggravation" (i.e., a nonservice connected disability aggravating a service connected disability). The VA examiner maintained that the Veteran's psychosocial stressors causing the adjustment disorder were exacerbating his PTSD. While some symptoms between the Veteran's PTSD and adjustment disorder with mixed anxiety and depressed mood overlap, the examiner was able to determine different and unique etiologies. As the Veteran's symptoms of depression and anxiety are contemplated by his already service-connected PTSD, and his diagnosis of adjustment mood was determined to be due to psychosocial stressors, the Veteran is not entitled to service connection for an acquired psychological disorder, other than PTSD. Finally, while the Veteran may believe he has an additional acquired psychiatric disorder other than PTSD that is related to his active service, he has not provided any sufficiently probative evidence to support his claim of service connection. The Board acknowledges that lay evidence may be sufficient to establish a causal relationship between a current disability and service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, however, as the medical question in issue is complex in nature, the Board finds that the Veteran's opinion as to the etiology of his depression and anxiety does not create the requisite nexus needed for service connection on a direct or secondary basis. While the Veteran's mood, anxiety level, and anxiety attacks are capable of lay observation, diagnosing an acquired psychiatric disability, is not capable of lay observation and is not a simple medical condition. See Jandreau, at 1377, n. 4. Diagnosing an acquired psychiatric disorder and the determination of an etiology for psychological symptoms is a complex medical issue requiring knowledge of the DSM criteria, and psychiatric principles; it is not capable of lay diagnosis and as such, the Board finds that the Veteran is not competent to provide the requisite nexus opinion for an acquired psychiatric disorder. See Woehlaert v. Nicholson. Furthermore, the medical evidence of record fails to provide a positive opinion regarding the Veteran's adjustment disorder with mixed anxiety and depressed mood to service, or to his service-connected PTSD. The Veteran's contention that he suffers from an acquired psychiatric disorder separate from his PTSD which is related to his service, is not sufficient to outweigh the medical opinions of record. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). In reaching the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claims, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected PTSD is denied. REMAND The Board finds that further development is required prior to adjudicating the Veteran's remaining claims. See 38 C.F.R. § 19.9 (2015). A Report of General Information from April 2015 indicates that the Veteran stated that he had been approved for Social Security Administration (SSA) Disability, and requested VA to obtain records from SSA. However, SSA records are not associated with the claims file and there is no indication that these records were ever requested. If, SSA records are potentially relevant to the Board's determination, VA is obliged to attempt to obtain and consider those records. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). The Veteran's Social Security records should be obtained prior to further review of his VA appeal. In a statement from the Veteran in October 2009, he stated that he has had a significant amount of trouble with his ears in the past, and noted that he suffers from a perforated ear drum. In a September 2009 rating decision the Veteran was service connected for tympanic membrane perforation of the left ear. Given the Veteran's frequent ear trouble, and ear complaints in-service, the Board finds that the Veteran's claimed bilateral hearing loss, tinnitus, and otitis media may be related to his service connected tympanic membrane perforation of the left ear. The Veteran's history of otitis media may have also caused or aggravated the Veteran's hearing loss and/or tinnitus. Thus, secondary service connection must be considered, and appropriate nexus opinions are necessary. See Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004); Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (when determining service connection, all theories of entitlement, direct and secondary, must be considered.). An addendum opinion to the November 2008 VA audio examination is necessary. The Board also notes that at the November 2008 VA Audiology examination, the Veteran denied having tinnitus and a nexus opinion was not provided. However, an audiology consult from November 2014 shows that the Veteran reported bilateral tinnitus. Thus, as tinnitus is a simple condition which can be diagnosed by a layperson, a nexus opinion should be obtained. Charles v. Principi, 16 Vet. App. 370, 374 (2002); Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, the Board finds that the condition of chronic otitis media, was noted upon entry into service. A July 31, 1970 notation indicates that chronic otitis media was noted by the examining physician at the Veteran's pre-enlistment Report of Medical Examination. Based upon this report, the Board finds that because the condition of chronic otitis media was diagnosed on the Veteran's entrance examination, the condition was "noted" upon entry into service. 38 C.F.R. § 3.304(b). Therefore, the presumption of soundness is rebutted and the Veteran's chronic otitis media preexisted service. Consequently, to the extent the Veteran seeks compensation for his chronic otitis media, the burden is on him to demonstrate an increase in disability during service, which would serve to establish the presumption of aggravation. See Wagner; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994); Horn v. Shinseki, 25 Vet.App. 231, 235 n. 6 (2012). The induction and/or enlistment Report of Medical Examination, also showed that the Veteran had some hearing loss at the 2000 Hertz level in his left ear. However, because the medical staff deemed the hearing loss as non-disabling, and the Veteran's hearing loss did not meet the requirements of 38 C.F.R. § 3.385, the Board finds that the Veteran's hearing was sound on entrance. VA is obliged to provide an examination when the record contains competent evidence that the Veteran has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's VAMC records show that he has a penile implant, and the Veteran alleged at his hearing that his erectile dysfunction is related to his PTSD and his medications taken for his PTSD, and/or his diabetes mellitus and medications taken for diabetes mellitus. See Hearing Transcript at 10-11. The Veteran also contended that his erectile dysfunction may be related to his alleged in-service sexual assault. See Hearing Transcript at 11. The Veteran should be afforded a VA examination to determine if his claimed erectile dysfunction is related to service, his PTSD, his diabetes mellitus, or any prescribed medication for his PTSD or diabetes. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Updated VA treatment records should be obtained as well. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain updated VA treatment records. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Contact the SSA and request the Veteran's complete SSA records, including any administrative decision(s) on his application for SSA disability benefits and all underlying medical records in SSA's possession. A copy of any request(s) sent to SSA, and any reply, to include any records obtained from SSA, must be included in the claims file. 3. Then, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his otitis media, hearing loss, and tinnitus. The claims file must be made available to the examiner for review and a notation to this effect should be made in the claims file. The complete medical history of the disability should be obtained. All necessary tests should be conducted. A) Otitis Media i. Is it at least as likely as not (a 50 percent or better probability) that the Veteran's preexisting chronic otitis media underwent a permanent increase in severity (as opposed to a temporary flare-up) during his active duty military service? ii. If yes, is it clear and unmistakable that the permanent increase in severity is due to the natural progression of the disability? The examiner should incorporate into the discussion the Veteran's in-service ear complaints, and ear treatment which include but are not limited to: March 1974 pain in his left ear, January 1976 in-service complaints of left ear ache, September 1977 complaints of ear congestion, July 1978 finding of right ear congestion with complaints of fluid in his ear, August 1978 clinical record showing frequent ear problems with hissing, pain, and drainage from his left ear and complaints to his right ear, August 1978 report of a long history of otitis media, and the September 1978 diagnosis of central perforation left tympanic membrane. The examiner should also incorporate the Veteran's statements made at his videoconference Board hearing that his chronic otitis media began in Vietnam, and that he experienced hearing sounds, and bone deterioration. B) Hearing Loss i. Based on the evidence of record, can it be determined with a reasonable degree of medical certainty that the Veteran has hearing loss within VA standards? ii. If the Veteran has developed hearing loss, is it at least as likely as not (50 percent or greater probability) that hearing loss had its onset during service, or was otherwise caused by any incident that occurred during service, including the Veteran's exposure to noise in the form of gun fire, and loud aircrafts? The examiner should discuss the November 2008 VA Audio Exam findings. iii. Is it at least as likely as not (50 percent or greater probability) that the Veteran's tympanic membrane perforation of the left ear is the cause of any currently diagnosed hearing loss? iv. Is it at least as likely as not (50 percent or greater probability) that the Veteran's tympanic membrane perforation of the left ear caused a worsening of any currently diagnosed hearing loss, beyond the normal progress of that disease? If such aggravation is found, the examiner should determine: (1) the baseline manifestations of the Veteran's hearing loss; and (2) the increased manifestations that are proximately due to the Veteran's service-connected tympanic membrane perforation of the left ear. v. Is it at least as likely as not (50 percent or greater probability) that the Veteran's otitis media is the cause of any currently diagnosed hearing loss? vi. Is it at least as likely as not (50 percent or greater probability) that the Veteran's otitis media caused a worsening of any currently diagnosed hearing loss, beyond the normal progress of that disease? If such aggravation is found, the examiner should determine: (1) the baseline manifestations of the Veteran's hearing loss; and (2) the increased manifestations that are proximately due to the Veteran's service-connected otitis media. C) Tinnitus i. Is it at least as likely as not (50 percent or greater probability) that tinnitus had its onset during service, or was otherwise caused by any incident that occurred during service, including the Veteran's exposure to noise in the form of gun fire, and loud aircrafts? ii. Is it at least as likely as not (50 percent or greater probability) that the Veteran's tympanic membrane perforation of the left ear is the cause of any currently diagnosed tinnitus? iii. Is it at least as likely as not (50 percent or greater probability) that the Veteran's tympanic membrane perforation of the left ear caused a worsening of any currently diagnosed tinnitus, beyond the normal progress of that disease? If such aggravation is found, the examiner should determine: (1) the baseline manifestations of the Veteran's tinnitus; and (2) the increased manifestations that are proximately due to the Veteran's service-connected tympanic membrane perforation of the left ear. iv. Is it at least as likely as not (50 percent or greater probability) that the Veteran's otitis media is the cause of any currently diagnosed tinnitus? v. Is it at least as likely as not (50 percent or greater probability) that the Veteran's otitis media caused a worsening of any currently diagnosed tinnitus, beyond the normal progress of that disease? If such aggravation is found, the examiner should determine: (1) the baseline manifestations of the Veteran's tinnitus; and (2) the increased manifestations that are proximately due to the Veteran's service-connected otitis media. The examiner should incorporate the Veteran's statements made at his videoconference Board hearing that he experiences "cricket sounds", that he experiences ringing in his ears which began in-service, and that at a November 2014 audiology consult he reported bilateral tinnitus. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached must be provided. If any requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his erectile dysfunction. The claims file must be made available to the examiner for review and a notation to this effect should be made in the claims file. The complete medical history of the disability should be obtained. All necessary tests should be conducted. i. Based on the evidence of record, can it be determined with a reasonable degree of medical certainty that the Veteran has erectile dysfunction? If the Veteran has developed any such disorder, is it at least as likely as not (50 percent or greater probability) that erectile dysfunction had its onset during service, or was otherwise caused by any incident that occurred during service, including the Veteran's alleged sexual assault in-service? ii. Is it at least as likely as not (50 percent or greater probability) that the Veteran's PTSD or diabetes mellitus, or the prescription medication used to treat his PTSD or his diabetes mellitus is the cause of any currently diagnosed erectile dysfunction? iii. Is it at least as likely as not (50 percent or greater probability) that the Veteran's PTSD or diabetes mellitus, or the prescription medication used to treat his PTSD or his diabetes mellitus caused a worsening of any currently erectile dysfunction, beyond the normal progress of that disease? If such aggravation is found, the examiner should determine: (1) the baseline manifestations of the Veteran's erectile dysfunction; and (2) the increased manifestations that are proximately due to the Veteran's service-connected PTSD or diabetes mellitus, or the prescription medication used to treat his PTSD or his diabetes mellitus. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached must be provided. If any requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 5. Thereafter, readjudicate the claims of (1) service connection for otitis media, to include as secondary to service-connected tympanic membrane perforation of the left ear, (2) service connection for hearing loss, to include as secondary to service-connected tympanic membrane perforation of the left ear, and/or otitis media, (3) service connection for tinnitus, to include as secondary to service-connected tympanic membrane perforation of the left ear, and/or otitis media, and (4) service connection for erectile dysfunction, to include as secondary to PTSD to include medications taken for PTSD, and/or diabetes mellitus, to include medications taken for diabetes mellitus. If the benefits sought on appeal remain denied, the Veteran and his representative should be issued a supplemental statement of the case, and given an opportunity to respond before the case is returned to the Board. The appellant 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). ______________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs