Citation Nr: 21002227 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 20-04 859 DATE: January 13, 2021 REMANDED Entitlement to service connection for a left scrotum disability, to include an epidydimal cyst, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1958 to August 1961. This matter comes before the Board of Veteran’s Appeal (Board) on appeal from a November 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a left scrotum disability, to include an epidydimal cyst, is remanded. The Board finds that the issue of entitlement to service connection for Veteran's left scrotum disability must be remanded for further development. In October 2018, the Veteran was afforded a VA examination. In the associated opinion, the VA examiner provided no diagnosis for the Veteran’s left scrotum pain and discomfort because she reasoned that there was no cyst detected either in service or during the March 2018 ultrasound. However, the examiner failed to identify the cause of the Veteran’s pain and offer an opinion as to whether the discomfort was related to service. Additionally, the examiner failed to address the growth found on the left testicle or the bilateral modules in the Veteran’s epididymis found during service. See Service Treatment Records dated January 1959, March 1961, and October 1960. The examiner also failed to address the mild hydrocele found in his left testicle during the March 2018 ultrasound. See March 2018 Private Treatment Record. Accordingly, pursuant to Clemons v. Shinseki, the Board finds that the issue should be recharacterized as entitlement to service connection for a left scrotum disability. See Clemons, 23 Vet. App. 1 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). Based on the foregoing deficiencies, an addendum opinion is warranted. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). The addendum opinion should acknowledge and address the growth found in the Veteran’s left testicle in service. The examiner should also determine the etiology of the Veteran’s hydrocele condition and whether it is related to service. Further, there appears to be outstanding private treatment records. Specifically, in the December 2020 IHP, the Veteran's representative asserted that the Veteran has continually received treatment for a left scrotum condition prior to and during the appeal. See December 2020 IHP. However, there are no VA treatment records or private treatment records in the Veteran’s file, aside from the October 2018 VA medical opinion and the March 2018 ultrasound. A remand is required to allow VA to obtain authorization to request these records. In ordering a remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran’s lay reports.  Rather, the Board is merely requesting that the examiner on remand consider the Veteran’s own descriptions of the history of his left scrotum disability. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all private medical care providers who treated him for his left scrotum disability after service. After securing any necessary releases, the AOJ should request any relevant records identified. If any requested records cannot be obtained, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. After the instruction in paragraph 1 is completed, send the claims to a qualified clinician for an opinion regarding the nature and etiology of the Veteran's current left scrotum condition, including but not limited to the March 2018 diagnosis of mild hydrocele. In doing so, the examiner should note that the term “current” means occurring at any time during the pendency of the Veteran’s claim. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. For each diagnosed left scrotum condition, the examiner(s) should state whether it at least as likely as not that the condition (1) began during any period of active service, (2) manifested within a year after discharge from active service, (3) was noted during service with continuous symptoms since service, or (4) is otherwise related to service. In providing the foregoing opinions, the examiner(s) should address the evidence of a growth on the left testicle and the tenderness noted at the head of the left epididymis during service. See March 1961 Service Treatment Record. Please review the following medical records in providing the foregoing opinion: (a.) Service Treatment Records dated January 1959, October 1960, and March 1961; and (b.) the March 2018 ultrasound report finding of mild hydrocele in the left testicle. For the purpose of providing the opinion requested, please accept as valid the Veteran’s statements that he has experienced left scrotum pain and discomfort since service, and state whether a nexus between the Veteran’s left scrotum disability and service is medically consistent with the information provided by the Veteran. (The Board reminds the Veteran that in asking the examiner to accept the history he provided, the Board is not at this time making an assessment of the credibility of his statements).    The examiner should provide a complete rationale for any opinion rendered. If the examiner’s opinion is negative, he or she must clearly explain why. If he or she cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why that is so. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Foster 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.