Citation Nr: 18148984 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-61 941 DATE: November 8, 2018 REMANDED Entitlement to service connection for headache disorder is remanded. Entitlement to service connection for sleep disorder with memory loss is remanded. Entitlement to a compensable initial rating for hypertension is remanded. Entitlement to an initial rating in excess of 10 percent for right hip degenerative joint disease is remanded. Entitlement to a compensable initial rating for left ankle lateral collateral sprain is remanded. Entitlement to a compensable initial rating for erectile dysfunction is remanded. Entitlement to a compensable initial rating for epididymectomy is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1992 to May 1992 and from October 1993 to March 2014. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in June 2015 by a Department of Veterans Affairs (VA) Regional Office. REASONS FOR REMAND Initially, the Veteran’s June 2015 notice of disagreement indicates the existence of outstanding, available treatment records, to include records pertaining to hospitalization for headaches and sleep disorders. The Veteran has not provided the names of any private treating physicians. On remand, the RO should request the Veteran identify such and then attempt to obtain all identified medical records. 1. Entitlement to service connection for headache disorder is remanded. 2. Entitlement to service connection for sleep disorder with memory loss is remanded. The Veteran asserts he has a headache disorder and sleep disorder with memory loss due to in-service head injuries. The Veteran underwent VA examinations in May 2015 in connection with these issues. The pertinent examination report reflects a diagnosis of tension headaches; however, the examiner found the Veteran’s condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner found there was insignificant history for headaches and no evidence of treatment for headaches while on active duty. Concerning a sleep disorder, the examiner provided a nexus opinion that focused on the lack of a current mental health disorder. Upon review, the Board finds the examinations inadequate. First, the proffered medical opinions do not address the evidence showing in-service treatment for head injuries, which are the basis for the Veteran’s assertions for entitlement to service connection. Specifically, a July 2005 report of medical history (received 9/8/14, page 51 of 341) indicates a “concussion [following] epididymectomy” with “no sequelae.” An August 1997 service treatment record (received 9/8/14, page 138 of 341) states that the Veteran “passed out and hit head on floor” while sick at home. A January 1996 radiology report (received 9/8/14, page 298 of 341) indicates a “[s]yncopal episode with injury to the head.” A March 1994 service treatment record (received 9/8/14, page 191 of 341) indicates a laceration on the Veteran’s head from hitting a piece of equipment with some dizziness but no loss of consciousness. In addition, the examination for the claimed sleep disorder does not appear to address the issue of a sleep disorder. As a result, remand is warranted for additional examination and medical opinions to determine whether any headache disorder and/or sleep disorder is related to service, to include the reported in-service head injuries. 3. Entitlement to a compensable initial rating for hypertension is remanded. As noted above, the Veteran indicates there are additional, outstanding treatment records pertinent to his claims. As such could potentially impact the rating of the Veteran’s service-connected hypertension, the Board finds a decision on this issue herein would be premature. 4. Entitlement to an initial rating in excess of 10 percent for right hip degenerative joint disease is remanded. 5. Entitlement to a compensable initial rating for left ankle lateral collateral sprain is remanded. A VA examination of the joints must, wherever possible, include range of motion testing for pain on active motion, passive motion, weight-bearing, nonweight-bearing, and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 169–70 (2016). As the May 2015 VA examination reports do not contain such findings, the Board finds additional examinations are warranted to determine the current nature and severity of the Veteran’s right hip degenerative joint disease and left ankle lateral collateral sprain. 6. Entitlement to a compensable initial rating for erectile dysfunction is remanded. 7. Entitlement to a compensable initial rating for epididymectomy is remanded. Under Diagnostic Code 7522, a 20 percent rating is appropriate for a deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b (2017). Under this code, a deformity means “a distortion of the penis, either internal or external.” Williams v. Wilkie, No. 16-3252, 2018 U.S. App. Vet. Claims LEXIS 1037, at *10 (Vet. App. Aug. 7, 2018). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2017). Upon examination of the Veteran’s erectile dysfunction and epididymectomy in May 2015, the VA examiner noted the Veteran had a scar related to prior surgeries, to include the Veteran’s epididymectomy. As the presence of the scar could constitute a deformity of the penis, and therefore warrant a higher/separate rating for the issues on appeal, an addendum opinion and, if necessary, additional examination is required to assess whether any surgical residuals of these surgeries, to include the diagnosed scar, constitute a distortion of the penis, internal or external. The matters are REMANDED for the following actions: 1. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment. Then take appropriate measures to obtain copies of any outstanding records identified by the Veteran, including treatment for headaches and a sleep disorder with memory loss, as discussed in his June 2015 notice of disagreement. The Veteran should be notified if any identified records are unavailable and given an opportunity to respond and submit any additional lay evidence or statements. 2. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran has any current or previously-diagnosed headaches; (b.) Whether it is at least as likely as not (i.e. a 50 percent or better probability) that any current or previously-diagnosed headaches were incurred in the Veteran’s service; (c.) Whether the Veteran has any current or previously-diagnosed sleep disorder with memory loss; and (d.) Whether it is at least as likely as not (a 50 percent or better probability) that any current or previously-diagnosed sleep disorder with memory loss was incurred in the Veteran’s service. In rendering these opinions, the examiner should consider service treatment records discussing head injuries, including those dated July 2005 (noting “concussion [following] epididymectomy” with “no sequelae,” received 9/8/14, page 51 of 341), August 1997 (received 9/8/14, page 138 of 341), January 1996 (received 9/8/14, page 298 of 341), and March 1994 (received 9/8/14, page 191 of 341). The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 3. After obtaining any additional records to the extent possible, provide an examination and obtain a medical opinion regarding the nature and severity of the Veteran’s service-connected right hip and left ankle disorders. The claims folder should be made available to the examiner for review prior to the examination and the examiner should acknowledge such review in the examination report. a. Full range of motion testing must be performed where possible. The joint involved should be tested in both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain the basis for this decision. b. The examiner should determine whether the Veteran’s service-connected hip and ankle disorders are manifested by weakened movement, excess fatigability, incoordination, pain or flare-ups. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, pain or flare-ups. c. The examiner should also request the Veteran identify the extent of his functional loss during flare-ups and, if possible, offer range of motion estimates based on that information. If the examiner is unable to provide an opinion on the impact of any flare-ups on the Veteran’s range of motion, the examiner should indicate whether this inability is due to lack of knowledge among the medical community or based on the lack of procurable information. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so, and must state whether there is additional evidence that would permit the necessary opinion to be made. (Continued on the next page)   4. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide an opinion as to whether the Veteran’s erectile dysfunction or epididymitis, to include any residuals from the surgeries in connection thereof, constitute a distortion of the penis, either internal or external. The need for additional examination is left to the examiner’s discretion. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. M. M. Celli Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Cannon, Associate Counsel