Citation Nr: 21002175 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-40 358 DATE: January 12, 2021 REMANDED Service connection for erectile dysfunction.   REASONS FOR REMAND The Veteran served on active duty from October 1968 to October 1970. The case is on appeal from a June 2015 rating decision. In August 2019, the Veteran testified at a Board hearing. In September 2019, the Board remanded the claim for additional development. Service connection for erectile dysfunction. The Veteran contends he has erectile dysfunction that is related to his service-connected disabilities, to include ischemic heart disease and posttraumatic stress disorder (PTSD), or alternatively to Agent Orange exposure. The Veteran underwent an April 2016 VA examination. The examiner noted a diagnosis of erectile dysfunction. The examiner opined that the Veteran’s erectile dysfunction is less likely than not related to his service-connected ischemic heart disease, status post coronary artery disease. The examiner explained there is no direct causality between ischemic heart disease and erectile dysfunction as both conditions are caused by atherosclerosis. Instead, the examiner opined that the Veteran’s erectile dysfunction is more likely than not due to his hypertension. The examiner explained hypertension causes erectile dysfunction due to microvascular complications and has a more direct causality to erectile dysfunction than coronary artery disease. This opinion did not address whether the Veteran’s erectile dysfunction is secondary to the Veteran’s service-connected PTSD or address whether the Veteran’s erectile dysfunction was related to his presumed exposure to Agent Orange based on his service in Vietnam. Pursuant to the Board’s September 2019 remand, the Veteran underwent a second VA examination in October 2019. With regard to direct service connection, the examiner provided a negative etiology. He explained the Veteran’s erectile dysfunction was diagnosed in 2006, which is 36 years after service. The examiner also concluded the Veteran’s erectile dysfunction is not caused or aggravated by his service-connected ischemic heart disease or PTSD. The examiner explained that the Veteran’s erectile dysfunction is more likely than not caused by his hypertension or due to his hypertensive treatment. In this case, a new examination and etiology opinion is needed on remand, as the opinions of record are not entirely adequate to resolve the medical questions at issue regarding this claim. First, concerning direct service connection, the examiner who provided the September 2019 examination limited the rationale for his opinion to the onset of the Veteran’s erectile dysfunction occurring 36 years after service. As such, the examiner failed explicitly address whether the Veteran’s erectile dysfunction is related to his exposure to Agent Orange or how the onset of the Veteran’s erectile dysfunction 36 years after service makes it less likely than not that the erectile dysfunction is related to his exposure to Agent Orange. In addition, although the examiner concluded that it is less likely than not that the Veteran’s erectile dysfunction is caused by or aggravated by his service-connected ischemic heart disease or his PTSD, the rationale for this conclusion only addresses causation. As such, he did not provide a rationale pertaining secondary aggravation. Accordingly, there was not substantial compliance with the Board’s remand directives, and a new examination and opinion are warranted on remand. See Stegall v. West, 11 Vet. App. 268 (1998); see D’Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). Moreover, the Board notes that in its September 2019 remand, it directed the RO to consider whether service connection should be granted for hypertension in light of the Veteran’s presumed exposure to Agent Orange; his hypertension diagnosis; the National Academy of Science (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 11 (2018) upgrade of hypertension to the category of “sufficient” evidence of an association with Agent Orange; and the April 2016 VA opinion. Although the claims file reflects that the Veteran was mailed a claim form in order to file a claim for hypertension, he has yet to return it. Accordingly, the Board finds the Veteran should be provided with another opportunity to file a claim for service connection for hypertension, as the outcome of the present issue could depend on it. In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records since September 2020. 2. Thereafter, schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of his erectile dysfunction. After review of the entire claims file, the examiner should opine as to the following: Is it at least as likely as not (a 50percent or greater probability) that the Veteran’s erectile dysfunction had its onset during, or is otherwise related to, the Veteran’s military service, to include as due to exposure to herbicide agents? Is it at least as likely as not (a degree of probability of 50 percent or higher) that the Veteran’s erectile dysfunction is caused by his service-connected PTSD or ischemic heart disease? Is it at least as likely as not (a degree of probability of 50 percent or higher) that the Veteran’s erectile dysfunction is aggravated by his service-connected PTSD or ischemic heart disease? “Aggravation” is an increase in disability beyond the natural progress of the disease. All opinions expressed should be accompanied by supporting rationale. 3. Adjudicate the claim of service connection for hypertension, including as due to exposure to Agent Orange. 4. Thereafter, reconsider the claim of service connection for erectile dysfunction. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Gray, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.