Citation Nr: 18147576 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 15-07 593 DATE: November 5, 2018 REMANDED Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus type II is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II is remanded. Entitlement to service connection for kidney stones is remanded. Entitlement to service connection for an enlarged prostate is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1968 to April 1969, with service in the Navy Reserve from November 1967 to January 1994, with various periods of active duty for training (ACDUTRA). These matters are before the Board of Veterans’ Appeals (Board) on appeal from a December 2012 decision of a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for erectile dysfunction and service connection for hypertension are remanded. The Veteran claims he is entitled to service connection for erectile dysfunction and hypertension, both as secondary to his service-connected diabetes mellitus type II. The Veteran submitted private medical nexus opinions in May 2012 and he was provided a VA examination in November 2012. As applicable to erectile dysfunction, the November 2012 VA examiner opined that the Veteran’s erectile dysfunction was less likely than not related to service-connected diabetes mellitus type II because erectile dysfunction was diagnosed prior to diabetes mellitus type II and that low testosterone may be the cause. The May 2012 private opinion reflects that the Veteran’s erectile dysfunction was at least as likely as not related to or aggravated by his claimed enlarged prostate, and that diabetes is shown to contribute to erectile dysfunction. As applicable to hypertension, the November 2012 VA examiner opined that hypertension was less likely than not related to service-connected diabetes mellitus type II because hypertension predated the diagnosis of diabetes mellitus type II and there “is no evidence for aggravation either.” The May 2012 private opinion states that hypertension was at least as likely as not related to or aggravated by diabetes mellitus type II, especially if, as in the Veteran’s case, he also has (non-service connected) hyperlipidemia. Initially, the Board notes that there are two opinions of record for each issue adjudicated herein, however neither opinion is sufficient for rating purposes. First, the May 2012 private opinions provide positive nexus opinions and address the matter of aggravation, which is paramount for this Veteran’s claim. However, they do not provide sufficient supporting rationale to support the Veteran’s claims, specifically in light of the contradicting VA nexus opinions. However, as applicable to the November 2012 VA opinions, the Board notes that when VA undertakes to provide a VA examination or to obtain a VA opinion, it must ensure that the examination or opinion is adequate. Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (stating that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The VA opinions provided in November 2012 are also not adequate for rating purposes as the VA examiner primarily relied upon the premise that because diagnoses of erectile dysfunction and hypertension pre-dated the official diagnosis of diabetes mellitus type II, they were not related. However, the VA examiner did not discuss aggravation in the erectile dysfunction opinion and provided nothing but a bare statement with no supporting rationale as part of the hypertension opinion. Further, although the private opinions were of record at the time of the VA examination, it is unclear from the opinion provided whether the VA examiner reviewed and considered the private opinions. As such, the Veteran should be afforded the opportunity for another VA examination and adequate VA opinions regarding his claimed conditions. 2. Entitlement to service connection for kidney stones and service connection for an enlarged prostate are remanded. The Veteran also claims he is entitled to service connection for kidney stones and an enlarged prostate. The Veteran has been denied for these conditions as they are not noted on his active duty service treatment records, but are noted during his time in the Navy Reserve; however, it is unclear whether they occurred during a period of ACDUTRA. Presently, the VA only has the Veteran’s reserve personnel records up to March 1987, and dates of ACDUTRA service are not included. A Veteran is entitled to service connection if he is disabled or died from a disease or an injury incurred in or aggravated in the line of duty during ACDUTRA service. As the Veteran served in the Navy Reserve until January 1994, on remand it is necessary to obtain reserve records from March 1987 to January 1994 and to request the specific dates of the Veteran’s ACDUTRA service, as they are required to determine if his claimed conditions were incurred or aggravated during any period of ACDUTRA. The Veteran is also in receipt of VA treatment for his claimed disabilities, on remand updated treatment records should be obtained. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s complete service personnel records and service treatment records, to include all documents pertaining to his service in the Navy Reserve. Verify all active duty for training and inactive duty training dates for service in the Navy Reserve from November 1967 to January 1994. If necessary, a request should be made to the Defense Finance and Accounting Service (DFAS). Document all requests for information as well as all responses in the claims file. 2. Obtain the Veteran’s VA treatment records from August 2016 to the present. 3. After completion of 1 and 2 above, schedule the Veteran for a VA examination by an appropriate VA clinician to determine the nature and etiology of the Veteran’s currently diagnosed erectile dysfunction and hypertension. The claims file must be made available to the examiner(s). Based on review of the pertinent evidence of record, (and any tests, studies or examination deemed necessary) the examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or better probability) that erectile dysfunction is caused or aggravated by (where aggravation is any increase in severity beyond the natural progress of the disability) his service-connected diabetes mellitus type II? The examiner is advised that for a veteran to be service connected on a secondary basis under a causation theory, the primary disability need not be service connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131 (2017). Thus, if the record reflects a diagnosis of diabetes mellitus subsequent to the initial diagnosis of erectile dysfunction, this alone is not a sufficient basis for a negative opinion as to causation. Rather, the examiner must consider whether diabetes may have been present, but undiagnosed, prior to the diagnosis of erectile dysfunction. (b) Is it at least as likely as not (50 percent or better probability) that hypertension is caused or aggravated by (where aggravation is any increase in severity beyond the natural progress of the disability) his service-connected diabetes mellitus type II? The examiner should note that the dates of diagnosis are not in and of themselves a reason that causation or aggravation is not present and additional rationale is required. The examiner is advised that for a veteran to be service connected on a secondary basis under a causation theory, the primary disability need not be service connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131 (2017). Thus, if the record reflects a diagnosis of diabetes mellitus subsequent to the initial diagnosis of hypertension, this alone is not a sufficient basis for a negative opinion as to causation. Rather, the examiner must consider whether diabetes may have been present, but undiagnosed, prior to the diagnosis of hypertension. 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. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD LM Stallings, Associate Counsel