Citation Nr: 18158683 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 15-10 135A DATE: December 18, 2018 REMANDED Entitlement to service connection for left retroperitoneal hemorrhage/hematoma (claimed as numbness and pain in lower abdomen), to include as secondary to service connected disease or injury is remanded. Entitlement to service connection for hepatic cysts (claimed as liver condition), to include as secondary to service connected disease or injury is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service connected disease or injury is remanded. Entitlement to service connection for acute renal failure (claimed as kidney condition), to include as secondary to service connected disease or injury is remanded. Entitlement to a rating in excess of 20 percent for recurrent deep vein thrombosis with post-thrombotic syndrome, left leg, is remanded. Entitlement to a rating in excess of 20 percent for recurrent deep vein thrombosis with post-thrombotic syndrome, right leg, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1963 to May 1967. 1. Entitlement to Service Connection for Left Retroperitoneal Hemorrhage/Hematoma, to include as Secondary to Service Connected Disease or Injury 2. Entitlement to Service Connection for Hepatic Cysts, to include as Secondary to Service Connected Disease or Injury 3. Entitlement to Service Connection for Erectile Dysfunction, to include as Secondary to Service Connected Disease or Injury 4. Entitlement to Service Connection for Acute Renal Failure, to include as Secondary to Service Connected Disease or Injury The Veteran contends that his liver and kidney disabilities, and his erectile dysfunction and hepatic cysts are entitled to service connection because they were caused by his service-connected recurrent deep vein thrombosis. See March 2012 Fully Developed Claim and March 2015 VA Form-9. Service treatment records show that the Veteran experienced multiple episodes of cellulitis with thrombophlebitis of the right and left legs. In June 1978, an RO granted service connection for bilateral thrombophlebitis with cellulitis. Private medical record show that the Veteran experienced a retroperitoneal hemorrhage in July 2011 from which he recovered but the bleed recurred in October 2011. In a discharge summary from a private hospital in November 2011, the attending physician noted that the Veteran experienced left femoral nerve palsy caused by a hematoma. He required hospitalization that included surgery for nerve decompression, evacuation of the hematoma, embolization of the L1 and L2 lumbar arteries, and treatment for acute renal and liver failure. The treatment for liver and renal failure appeared to be successful as the attending physician did not continue these diagnoses at discharge from the hospital and follow-up treatment in December 2011 only addressed residuals from the left femoral nerve compression. Although the Veteran was afforded a VA examination in July 2012. A VA nurse practitioner (NP) reviewed the file that contained the private medical reports noted above and accurately summarized the events and medical treatment for the abdominal hemorrhage, left femoral nerve, and renal and liver function treatment. The NP found that the liver and renal function had resolved. The NP further found that L1 and L2 artery pseudoaneurysms were the cause of the retroperitoneal bleed, hemorrhage, and left femoral nerve compression. The NP found no anatomic relationship between the service-connected bilateral thrombophlebitis with cellulitis, which involved thrombosis and swelling in the venous vasculature, and the pseudoaneurysms of the lumbar spine arterial system that “have nothing to do with the veins of the lower legs.” The NP cited a review of unspecified medical literature to support the conclusion that the two vascular systems were separate with no anatomical or functional interconnection. The NP thus found that the hemorrhage/hematoma and erectile dysfunction were not caused by the service-connected venous thrombosis and, as noted, that the liver and renal failures were acute and resolved. The Veteran contends that the VA examiner’s conclusions were based on incorrect medical information, and did not contemplate the medical evidence he submitted with his claim. He did not explain what information in the examination report was incorrect or what medical evidence was not considered. He also stated that the examiner did not take his past medical history into consideration but did not indicate what history was overlooked. He did not comment on whether he continues to experience liver and renal dysfunction. A VA examination for vascular diseases in December 2013 addressed the service-connected lower extremity venous insufficiencies but not the residuals, if any, of the 2011 arterial aneurysm. VA primary care records through October 2013 mention left leg nerve damage, cellulitis, and varicose veins but not abdominal pain, renal, liver, or erectile dysfunction. As this is a complex medical matter, the Board finds that an additional medical examination to determine whether at any time during the pendency of the appeal from March 212 the Veteran has residual disabilities of abdominal pain, renal, liver, and erectile dysfunction and if so an opinion whether any residual disabilities arise from the October/November aneurysm/hemorrhage, left femoral nerve compression, acute renal and liver dysfunction and were caused or aggravated by the service-connected bilateral thrombophlebitis with cellulitis. 5. Entitlement to a Rating in excess of 20 Percent for Recurrent Deep Vein Thrombosis with Post-Thrombotic Syndrome, Left Leg is Remanded. 6. Entitlement to a Rating in excess of 20 Percent for Recurrent Deep Vein Thrombosis with Post-Thrombotic Syndrome, Right Leg is Remanded. On his March 2015 VA Form-9, the Veteran reported that his service-connected right and left leg recurrent deep vein thrombosis had worsened. He stated that his right leg persistent edema was no longer relieved by elevation and he had lost sensation. He reported that his left leg was consistently swollen with redness and pain. He also reported loss of use with his left leg. The duty to get a new examination is triggered only when the available evidence indicates that the previous examination no longer reflects the current state of the Veteran’s disability. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); VAOPGCPREC 11-95 (1995). In this instance, the Veteran has reported that his right and left leg service-connected disabilities have increased in severity and a new examination is needed to assess his current condition. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate with the claims file. 2. Contact the Veteran and request that he either provides any outstanding relevant private treatment records or completes a release for such providers; if any releases are returned, attempt to obtain the identified records. Provide the Veteran with a copy of the July 2012 VA examination. Request that he provide additional statements regarding his objection to the July 2012 examination; specifically, to explain what information in the examination report was incorrect, what medical evidence was not considered, and what history was overlooked. 3. Obtain VA opinions with respect to the Veteran’s liver, kidney, erectile dysfunction, and hepatic cysts disabilities. If the medical professional(s) determine that additional examinations of the Veteran are necessary to provide an adequate opinion, such examinations must be scheduled. The medical professional(s) must address the following: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any abdominal pain, liver, kidney, erectile dysfunction, and hepatic cysts disabilities were present at any time after March 2012 and whether any are caused by the Veteran’s service-connected recurrent deep vein thrombosis. (b.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any liver, kidney, erectile dysfunction, and hepatic cysts disabilities present after March 2012 have been aggravated (i.e., increased in severity) by the Veteran’s service-connected recurrent deep vein thrombosis. The examiner(s) are asked to address the October and November 2011 private treatment records and indicate agreement or disagreement with the findings of the VA examiner in July 2012 in any opinion rendered. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected recurrent deep vein thrombosis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Fitzgerald, Associate Counsel