Citation Nr: 18150517 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 11-04 317 DATE: November 15, 2018 REMANDED Entitlement to service connection for erectile dysfunction, including secondary to depression or depression medications is remanded. REASONS FOR REMAND The Veteran served in U.S. Army on active duty from February 1981 to August 1988. Entitlement to service connection for erectile dysfunction, including secondary to depression or depression medications is remanded. Although the Board sincerely regrets the additional delay, another addendum opinion is necessary to ensure there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. The Veteran asserts that the erectile dysfunction is caused by service-connected depression or depression medication. See April 2015 Notice of Disagreement. The Veteran has also made statements that he has a lack of sexual desire. See December 2014 Notice of Disagreement. In July 2017 the Board issued a remand for another medical opinion, and one of the directives required the examiner to include discussion of the Veteran’s December 2014 website printouts from drugs.com describing the side effects of his medication, notably, decreased sexual desire and failure to discharge semen. VA issued a medical opinion in July 2017 and the examiner failed to discuss this evidence. Further, the VA examiner issuing the July 2017 could not answer with regard to whether depression caused or aggravated the Veteran’s erectile dysfunction without speculating. The examiner stated “…this examiner cannot answer without use of speculation as mental health issues are not this examiner’s bailiwick.” See July 24, 2017 VA Medical Opinion. A VA addendum medical opinion was issued in January 2018 and that examiner also failed to address the July 2017 remand directive requiring discussion of the Veteran’s December 2014 evidence from drugs.com. Additionally, the January 2018 VA examiner failed to discuss whether the Veteran’s depression medications are causing his erectile dysfunction. The examiner stated that this directive had already been addressed by previous examiners. The examiner also stated, “Given that this examiner is a psychologist without detailed knowledge of the physiology and psychopharmacology of [erectile dysfunction] and medications, I will defer to the previous two medical opinions regarding the effects of depression medications being less likely a cause of any ED.” See January 23, 2018 Addendum VA Medical Opinion. As the record indicates, the evidence submitted by the Veteran in December 2014 from drugs.com was not addressed by any of the VA examiners. As such, the Board’s July 2017 remand directives have not been substantially complied with and a Stegall violation has occurred. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (remand by Board confers on a claimant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms). In addition, when VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that another VA medical opinion, one supported by adequate rationale and one that addresses all remand directives, is needed to appropriately resolve the claim. The matter is REMANDED for the following action: 1. Obtain a medical opinion from the appropriate VA medical professional regarding the Veteran’s erectile dysfunction. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner shall determine the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s erectile dysfunction had its onset during or was causally related to his service? The examiner shall keep in mind that opinions based solely on the absence of medical evidence may be deemed inadequate. (b.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s erectile dysfunction was caused by depression, to include any medications used to treat the Veteran’s depression? The examiner’s report must reflect consideration of the Veteran’s entire documented medical history, lay assertions and lay evidence. The examiner is specifically requested to address the Veteran’s December 2014 evidence submitted from drugs.com.   (c.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s erectile dysfunction was aggravated (permanently increased in severity beyond the natural progress of the disorder) by depression, to include any medications used to treat the Veteran’s depression? If the examiner determines that the Veteran’s erectile dysfunction is aggravated by his service-connected depression, to include any medications, the examiner should report the baseline level of severity of the erectile dysfunction prior to the onset of aggravation. The examiner’s report must reflect consideration of the Veteran’s entire documented medical history, lay assertions and lay evidence. The examiner is specifically requested to address the Veteran’s December 2014 evidence submitted from drugs.com. All opinions expressed by the examiner should be accompanied by a complete, clear rationale, with citation to relevant medical findings and lay statements. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation.   2. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response before the case is returned to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. N. Shannon, Associate Counsel