Citation Nr: 1800045 Decision Date: 01/03/18 Archive Date: 01/19/18 DOCKET NO. 10-41 880 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for inguinal nerve irritation/entrapment. 2. Entitlement to a disability rating in excess of 10 percent for a tender scar from left varicocele surgery. 3. Entitlement to service connection for deep vein thrombosis (claimed as blood clot in left leg), to include as secondary to the service-connected inguinal nerve irritation/entrapment or service-connected tender scar from left varicocele surgery. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to the service-connected inguinal nerve irritation/entrapment or service-connected tender scar from left varicocele surgery. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Smith, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from September 1945 to July 1946 and December 1953 to August 1955. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine. Jurisdiction is now with the RO in Detroit, Michigan. At the time of the February 2009 rating decision, the Veteran was rated at 20 percent for left varicocele operation scar with inguinal nerve irritation and entrapment history. In a July 2010 rating decision, the RO separated the rating into two separate evaluations of 10 percent for inguinal nerve irritation/entrapment and 10 percent for a tender scar from left varicocele surgery. Each rating is effective dating back to November 1, 1991. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Although further delay is regrettable, the Board finds that a remand is necessary for further evidentiary development of all of the Veteran's claims on appeal. Specifically, the Board finds that new VA examinations are required for each claim. Increased Ratings The Veteran filed a claim for increase regarding his left varicocele operation scar with inguinal nerve irritation and entrapment history. As mentioned in the Introduction, in July 2010, the RO separated this disability into separate evaluations under Diagnostic Code 8630 for an inguinal nerve irritation/entrapment and Diagnostic Code 7804 for a tender scar for left varicocele surgery. As such, the Veteran's claim for an increase now refers to those service-connected disabilities separately. The record reflects that the Veteran has not been examined regarding the severity and manifestations of his left varicocele operation scar with inguinal nerve irritation and entrapment history since January 1999. Nor has the Veteran been evaluated since the disability was re-evaluated under separate diagnostic codes. As the Veteran has since filed a claim for increase indicating that the disability has worsened, the Board determines that new VA examinations are necessary to assess the current severity and manifestations of the Veteran's service-connected inguinal nerve irritation/entrapment and his service-connected tender scar from left varicocele surgery. Service Connection The Veteran contends that his deep vein thrombosis and erectile dysfunction are secondary to his left varicocele operation scar with inguinal nerve irritation and entrapment history. While the Veteran underwent a VA examination for his deep vein thrombosis and erectile dysfunction in November 2008, that examination only addressed direct service connection for both conditions. There is no opinion of record addressing secondary service connection for either disability. As such, the Board determines that new VA examinations are necessary regarding secondary service connection for the Veteran's deep vein thrombosis and his erectile dysfunction. The Board notes that because the previously service-connected disability is now evaluated under two separate diagnostic codes, opinions on secondary service connection are necessary for both the Veteran's service-connected inguinal nerve irritation/entrapment and his service-connected tender scar from left varicocele surgery. As to direct service connection, the November 2008 VA examiner opined that neither the Veteran's deep vein thrombosis nor erectile dysfunction is related to his service. Regarding the Veteran's erectile dysfunction, the VA examiner rationalized that it is due to age, medications, and atherosclerosis. Regarding the Veteran's deep vein thrombosis, the November 2008 VA examiner's impression was that an ultrasound was negative and deep vein thrombosis was ruled out prior to the Veteran's discharge. The VA examiner indicated that however, the Veteran showed signs of potential deep vein thrombosis. The VA examiner noted that in 1992, the Veteran did have possible post deep vein thrombosis syndrome/thrombophletis most likely related to the possible deep vein thrombosis he had status post-surgery. The VA examiner opined that however, this condition has resolved. The VA examiner rationalized that the Veteran has no current problems and was no longer on Coumadin. The Board does not find the November 2008 VA opinion on the Veteran's deep vein thrombosis adequate. Following this examination, a September 2009 discharge summary note from Battle Creek VAMC indicates a diagnosis of deep vein thrombosis left lower extremity and popliteal and superficial femoral deep vein thrombosis. Additionally, Battle Creek VAMC records reflect consistent indications dating back to 1999 of the Veteran having a history of recurrent deep vein thrombosis. Thus, while the November 2008 VA examiner indicated that the Veteran did not show any current problems of deep vein thrombosis, this conclusion runs counter to the evidence of record. Furthermore, while the record reflects that the Veteran was prescribed Coumadin for recurrent blood clots in his left leg (See February 2000 consultation note from Battle Creek VAMC), there is no indication that the Veteran was removed from Coumadin because he no longer had blood clots or deep vein thrombosis. The record reflects that at times, the Veteran was removed from Coumadin for reasons unrelated to his blood clots or deep vein thrombosis. A March 2000 progress note from Battle Creek VAMC indicates that the Veteran was removed from Coumadin because he had been coughing up blood but that he was placed back on Coumadin. In a March 2006 progress note from Battle Creek VAMC records, a Dr. Cortez, in noting the Veteran's history of recurrent deep vein thrombosis, indicated that Dr. Eller, the cardiologist, had stopped the Veteran's Coumadin in June 2005 and advised him to take ASA only. There is no mention that the Veteran was removed from Coumadin because his blood clots or deep vein thrombosis had resolved. For the reasons discussed, the Board determines that a new VA examination is necessary for an adequate opinion regarding the nature and etiology of the Veteran's deep vein thrombosis. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Have the Veteran identify any additional treatment records regarding his inguinal nerve irritation/entrapment and his tender scar from left varicocele surgery. Send the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization, to enable the AOJ to obtain any additional evidence pertinent to the claim for increased ratings. If the Veteran identifies any other pertinent medical records that have not been obtained, the AOJ should undertake appropriate development to obtain a copy of those records. If the AOJ is unsuccessful in its efforts to obtain any such evidence, it should inform the Veteran and his representative of such and request that they submit the outstanding evidence. 2. After obtaining any additional records, schedule the Veteran for a VA peripheral nerves examination to ascertain the severity and manifestations of his service-connected inguinal nerve irritation/entrapment. 3. Schedule the Veteran for a VA examination with an appropriate examiner to assess the current severity, including functional effects, and manifestations of his service-connected tender scar from left varicocele surgery. Any tests deemed necessary should be conducted. The examiner must provide all information required for rating purposes. 4. Schedule the Veteran for a VA examination with an appropriate examiner to determine whether the Veteran has a current diagnosis for deep vein thrombosis and the nature and etiology of the disability. The examiner is asked to provide an opinion as to the following: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's deep vein thrombosis had its onset during or was caused by the Veteran's active service. (b) Whether the Veteran's deep vein thrombosis was caused (in whole or in part) or aggravated (permanently worsened) by the Veteran's inguinal nerve irritation/entrapment. (c) Whether the Veteran's deep vein thrombosis was caused (in whole or in part) or aggravated (permanently worsened) by the Veteran's tender scar from left varicocele surgery. 5. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran's claimed erectile dysfunction. The examiner is asked to provide an opinion as to the following: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's erectile dysfunction had its onset during or was caused by the Veteran's active service. (b) Whether the Veteran's erectile dysfunction was caused (in whole or in part) or aggravated (permanently worsened) by the Veteran's inguinal nerve irritation/entrapment. (c) Whether the Veteran's erectile dysfunction was caused (in whole or in part) or aggravated (permanently worsened) by the Veteran's tender scar from left varicocele surgery. For each examination requested, the claims file must be made available to the examiner, and the examiner should state in the opinion that review of the electronic record was accomplished. Additionally, the examiner is asked to review all pertinent records associated with the claims file and any assertions made by the Veteran regarding his symptoms. The examiner is advised that the Veteran is competent to attest to observable symptoms, such as pain. If there is a medical basis to support or doubt the Veteran's reports of symptomatology, the examiner should provide a fully reasoned explanation. 6. After completing the above actions, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, the Veteran should be furnished an appropriate Supplemental Statement of the Case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, as appropriate. The appellant has the right to submit additional evidence and argument on the 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). _________________________________________________ GAYLE E. STROMMEN 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) (2016).