Citation Nr: 1639405 Decision Date: 09/30/16 Archive Date: 10/13/16 DOCKET NO. 10-43 947 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected type II diabetes mellitus. 2. Entitlement to service connection for congestive heart failure with aortic valve stenosis and replacement, to include as due to herbicide exposure and as secondary to service-connected type II diabetes mellitus and/or coronary artery disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to February 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal of a November 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. When this case was before the Board in April 2014, it was remanded for additional development. The case is now again before the Board for further appellate action. The record before the Board consists of electronic records within Virtual VA and the Veterans Benefits Management System. FINDINGS OF FACT 1. The Veteran's erectile dysfunction is etiologically related to his service-connected type II diabetes mellitus. 2. The Veteran served on active duty in the Republic of Vietnam during the Vietnam War. 3. The Veteran's aortic valve stenosis qualifies within the generally accepted medical definition of ischemic heart disease; his aortic valve replacement and congestive heart failure are due to the aortic valve stenosis. CONCLUSIONS OF LAW 1. The criteria for service connection for erectile dysfunction have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. § 3.102, 3.310 (2016). 2. The criteria for service connection for congestive heart failure with aortic valve stenosis and replacement have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.307(a)(6), 3.309(e), 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As explained below, the Board has determined that the evidence currently of record is sufficient to substantiate the Veteran's claims of entitlement to service connection for erectile dysfunction and congestive heart failure with aortic valve stenosis and replacement. Therefore, no further development is required under 38 U.S.C.A. §§ 5103, 5103A (West 2014) or 38 C.F.R. § 3.159 (2016). Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2016). Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2016). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Background and Analysis Erectile Dysfunction The record shows the Veteran has been diagnosed with erectile dysfunction. He has asserted that this condition was caused or aggravated by his service-connected type II diabetes mellitus. The Veteran was afforded a VA diabetes examination in August 2012. On the examination report, the examiner checked the box indicating the Veteran's erectile dysfunction was at least as likely as not due to his diabetes. However, on a separate male reproductive system examination report, the examiner stated that the Veteran's erectile dysfunction was diagnosed in 2009, two years prior to his diabetes diagnosis, and therefore, although the examiner "could not say" what the etiology of the erectile dysfunction was, it was not related to diabetes. In its April 2014 remand, the Board noted the inconsistencies inherent in the August 2012 examination report, and instructed the originating agency to obtain an additional VA medical opinion. An opinion was obtained in May 2014. The examiner stated that based on the August 2012 examination report, the Veteran was diagnosed with erectile dysfunction in 2009, and type II diabetes mellitus in 2011. The examiner stated that in many instances, diabetes does aggravate erectile dysfunction, but because the Veteran's erectile dysfunction was diagnosed before his diabetes, the erectile dysfunction was less likely than not caused or aggravated by the diabetes. The Veteran was afforded additional VA diabetes and male reproductive system examinations in October 2015. The examiner checked the box indicating the Veteran's erectile dysfunction was at least as likely as not due to his diabetes mellitus. The examiner also noted the Veteran's report that his erectile dysfunction symptoms had begun 10 years prior. The examiner then specifically stated that the etiology of the Veteran's erectile dysfunction was his diabetes mellitus. The Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, 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 this regard, the Board notes that the August 2012 and May 2014 VA examiners' findings that the Veteran's erectile dysfunction was not caused or aggravated by his type II diabetes mellitus were based entirely on the diagnosis of erectile dysfunction pre-dating the diagnosis of diabetes mellitus. Both examiners, therefore, failed to address the possibility that the Veteran's erectile dysfunction, although already present when he was diagnosed with diabetes, was nonetheless aggravated, or permanently worsened, by the diabetes. As such, the Board finds the August 2012 and May 2014 VA examination reports to be inadequate for adjudication purposes, and otherwise to be of limited probative value. Upon a careful review of the foregoing, the Board finds that the evidence is at least in equipoise as to whether the Veteran's erectile dysfunction is etiologically related to his service-connected type II diabetes mellitus. In this regard, the Board notes that the October 2015 VA examiner indicated her awareness that the Veteran's erectile dysfunction symptoms pre-dated his diabetes diagnosis, but nonetheless found that the erectile dysfunction symptoms were related to the diabetes. As such, the Board infers that the examiner determined the Veteran's erectile dysfunction symptoms, although already present, were aggravated by his service-connected type II diabetes mellitus. Accordingly, granting of service connection for erectile dysfunction is warranted. The Board acknowledges that the level of disability that existed prior to the onset of aggravation is not clearly shown in this case but erectile dysfunction alone, regardless of the degree of severity, is considered noncompensably disabling under the schedular criteria. Therefore, further delay of the appellate process to determine the degree of severity of the erectile dysfunction before the onset of aggravation would serve no useful purpose in this case. Heart Disability The record shows that the Veteran was diagnosed with aortic stenosis related to congestive heart failure in November 2008, and that he underwent aortic valve replacement surgery shortly thereafter. He has also been diagnosed with non-obstructive coronary artery disease. The Veteran was afforded a VA examination in August 2010. The examiner noted the Veteran's aortic valve replacement surgery and provided a diagnosis of valvular heart disease. The Board notes that where a veteran served in the Republic of Vietnam during the Vietnam War, the veteran shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C.A. § 1116(a)(3) (West 2014); 38 C.F.R. § 3.307(a)(6)(ii) (2016). For these veterans, diseases associated with exposure to certain herbicide agents will be presumed to have been incurred in service even though there is no evidence of the disease during the period of service at issue. 38 U.S.C.A. § 1116 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2016). During the pendency of the Veteran's claim, ischemic heart disease was added to the list of diseases for which presumptive service connection may be established on the basis of herbicide exposure. Thus, as the law now stands, if a veteran was exposed to a herbicide agent during active service and manifests ischemic heart disease to a compensable degree at any time after such service, the ischemic heart disease will be service connected even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (2016). The record shows the Veteran served in the Republic of Vietnam during the Vietnam War. As a result of the Veteran's presumed exposure to herbicides in Vietnam, the RO obtained a VA medical opinion in April 2011 as to whether the Veteran's heart conditions were related to his presumed in-service herbicide exposure. In the April 2011 opinion, a VA orthopedist stated that the Veteran's non-obstructive coronary artery disease was at least as likely as not related to the Veteran's herbicide exposure, while his congestive heart failure with aortic valve stenosis and replacement was not caused by the herbicide exposure. The examiner stated that upon a review of the side effects of herbicide exposure, while a relationship between coronary artery disease and herbicides had been conceded, he had not heard of any effects of herbicides on the development of cardiac valvular disease. On the basis of the April 2011 opinion, in a February 2012 rating decision, the Veteran was granted service connection for ischemic heart disease in the form of his coronary artery disease, due to his presumed exposure to herbicides during service. However, service connection for the Veteran's congestive heart failure with aortic valve stenosis and replacement remained denied. The Veteran was afforded an additional VA examination in August 2012. The examiner noted the Veteran had been diagnosed with congestive heart failure and valvular heart disease. In its April 2014 remand, the Board noted the February 2012 grant of service connection for the Veteran's ischemic heart disease in the form of coronary artery disease. The Board noted that there had been no opinion rendered as to whether the Veteran's service connected coronary artery disease had caused or aggravated his congestive heart failure with aortic valve stenosis and replacement, and remanded the claim for an additional VA opinion. The opinion author was instructed to opine as to whether the Veteran's aortic stenosis was caused or aggravated by his coronary artery disease, and as to whether the cause of his congestive heart failure was his coronary artery disease, his aortic stenosis, or some other cause. In a May 2014 opinion, a VA examiner stated it was less likely than not that the Veteran's coronary artery disease caused or aggravated his aortic stenosis. The examiner further stated that there were no wall motion abnormalities involving the walls of the Veteran's left ventricle, and that his past echocardiogram results suggested that his severe aortic stenosis was the cause of his congestive heart failure. The examiner stated that when coronary artery disease caused congestive heart failure, it usually produced some wall motion changes and a depression of function in the left ventricle. The Veteran was afforded an additional VA examination in October 2015. The examiner noted the Veteran was service connected for ischemic heart disease, and had undergone an aortic valve replacement in November 2008. The examiner also noted the Veteran had had a dual-chamber pacemaker implanted in May 2015 due to a complete heart block. Importantly, the examiner indicated that the Veteran's valvular heart disease qualified within the generally accepted medical definition of ischemic heart disease. The examiner further indicated the Veteran's valvular heart disease was the condition which necessitated his November 2008 aortic valve replacement surgery. The examiner further noted that a July 2015 echocardiogram showed a left ventricular ejection fraction of 40 to 50 percent, as well as abnormal wall motion and thickness in the form of mild left ventricular hypertrophy. Upon a review of the foregoing, the Board finds the evidence supporting the claim is at least in equipoise with that against the claim. In this regard, the Board notes that only the October 2015 examiner provided an opinion as to whether the Veteran's aortic stenosis is a form of ischemic heart disease. The examiner answered this question affirmatively. The evidence also reflects that the aortic valve replacement was performed because of the aortic valve stenosis. In addition, the May 2014 examiner opined that the congestive heart failure was caused by the Veteran's aortic stenosis which the October 2015 examiner determined was caused by ischemic heart disease. Accordingly, service connection is warranted for the Veteran's congestive heart failure with aortic valve stenosis and replacement. ORDER Service connection for erectile dysfunction is granted. Service connection for congestive heart failure with aortic valve stenosis and replacement is granted. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs