Citation Nr: 18142910 Decision Date: 10/17/18 Archive Date: 10/17/18 DOCKET NO. 14-26 757 DATE: October 17, 2018 REMANDED Entitlement to service connection for erectile dysfunction, to include as secondary to posttraumatic stress disorder (PTSD), coronary artery disease, and medications for those disabilities, is remanded. Entitlement to special monthly compensation based on the need for aid and attendance is remanded. REASONS FOR REMAND Although the Board regrets the further delay, a remand is required for additional development and adjudicative action. 1. Entitlement to service connection for erectile dysfunction, to include as secondary to PTSD, coronary artery disease, and medications for those disabilities, is remanded. The Veteran underwent a VA examination in March 2011 and the examiner was requested to provide an opinion regarding the etiology of the Veteran’s erectile dysfunction and whether or not it was secondary to his PTSD, coronary artery disease, and medications for those disabilities. The March 2011 examiner indicated that he or she was unable to provide an opinion regarding the effect of behavioral medicine on erectile dysfunction and indicated that question would be best opined by a specialist. The examiner further indicated that the multiple medications taken by the Veteran could have inhibitory effects on libido and ejaculation but would not necessarily result in erectile dysfunction or impotence. The examiner then stated that there was “no medical evidence to support an etiology or direct causal relationship of erectile dysfunction or impotence to any medical events/conditions related to military service or any aggravation by any such medical events or conditions and no clear etiologies indicated by the many and varied medical and lab work-ups.” The Board finds this opinion is cursory and does not actually explain or provide a basis for the examiner’s conclusion that the Veteran’s erectile dysfunction is not secondary to his coronary artery disease or any medications for that disease. The Veteran underwent a VA examination in January 2012 and the examiner, a mental health specialist, provided a March 2012 opinion regarding the etiology of the Veteran’s erectile dysfunction. The VA mental health specialist opined that the Veteran’s erectile dysfunction was less likely than not secondary to his PTSD or any medication for that disorder, and provided a thorough explanation. The examiner based this opinion on a review of the clinical records, interviews with the Veteran and his wife, the examiner’s medical and clinical experience. Notably, the examiner pointed out that the Veteran’s “major difficulties with erectile dysfunction began around the time that his vascular disease (and other medical conditions affecting circulation) would have been developing.” As noted above, one of the Veteran’s vascular disorders is coronary artery disease, and he is claiming that his erectile dysfunction is secondary to his coronary artery disease or any medications for that disease. Given that the March 2011 opinion is cursory and does not adequately explain the lack of a relationship between the Veteran’s erectile dysfunction and coronary artery disease, or medication for that disease, and given that the March 2012 opinion points to the onset of erectile dysfunction when the Veteran’s vascular disorders began, the Board finds a new opinion is required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 2. Entitlement to special monthly compensation based on the need for aid and attendance is remanded. In a September 2018 brief in support of his claim, the Veteran’s representative argued that the Veteran was entitled to special monthly compensation based on the need for aid and attendance due to the fact that the Veteran now requires the assistance of a caregiver. The representative indicated that a VA caregiver visits the Veteran at his home; when the VA caregiver is not at his home, and his wife has to leave the home, someone else has to come assist him with his medications. The representative further argued that the Veteran was unable to perform his normal activities of daily living due to his service-connected disabilities. Significantly, the most recent VA treatment records associated with the evidence of record are dated June 2014. Given that the representative’s statements suggest a worsening of the Veteran’s condition, and because the most recent evidence of record is more than four years old, the Board finds a remand is required to obtain all outstanding VA treatment records and to afford the Veteran the appropriate VA examinations to determine all functional impairment due to his service-connected disabilities. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the evidence of record before the Board. 2. Afford the Veteran the appropriate VA examinations to evaluate the impairment due to all of his service-connected disabilities for the purposes of determining whether entitlement to special monthly compensation based on aid and attendance is appropriate. The examiners should ensure the medical examination reports include a discussion of all functional impairment caused by the Veteran’s service-connected disabilities. 3. Afford the Veteran the appropriate VA examination to determine the etiology of his erectile dysfunction. The entire claims file must be made available to and reviewed by the examiner. The examiner must obtain from the Veteran and document in the examination report a complete history of the onset and continuity of symptoms of erectile dysfunction. Following a complete review of the evidence of record, and with consideration of the Veteran’s lay statements, the examiner is requested to provide the following medical opinions: (a) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s erectile dysfunction is caused by his coronary artery disease. (b) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s erectile dysfunction is aggravated by his coronary artery disease. (c) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s erectile dysfunction is caused by any medications taken for his coronary artery disease. (d) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s erectile dysfunction is aggravated by any medications taken for his coronary artery disease. In providing these opinions, the examiner MUST discuss the onset and/or aggravation of erectile dysfunction as it relates to the onset and/or aggravation of his coronary artery disease. A complete rationale for ALL opinions rendered must be provided. Citation to medical literature and accepted medical principles will be of great assistance to the Board. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 4. The AOJ must review the examination report and opinions to ensure they are adequate and that they comply with the Board’s specific remand directives. If deficient in any manner, corrective action must be taken at once. 5. The Veteran is informed that it is his responsibility to report for any scheduled examinations and to cooperate in the development of the claims and that the consequences for failure to report for any VA examination without good cause may include denial of a claim. See 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation showing that he was properly notified of the examination must be associated with the record. (CONTINUED ON NEXT PAGE) 6. Then, the Veteran’s claims must be readjudicated. If any benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jessica O'Connell, Associate Counsel